Definitions of Suicide and Self‑Harm
Self‑harm: Self‑directed behavior that deliberately results in injury or the potential for injury. It can occur with or without suicidal intent.
Suicide attempt: A self‑injurious behavior for which the person had at least some intent to die; may result in death, injuries, or no injuries.
Suicide: Death caused by self‑directed behavior with an intent to die as a result of the behavior.
Source: The National Institute of Mental Health’s website and a model school district policy on suicide prevention created by the Trevor Project and other suicide prevention nonprofits.
Suicide prevention is an issue of state and national importance. According to the Centers for Disease Control and Prevention (CDC), in 2017 suicide was the second leading cause of death nationwide among young people ages 10 to 24.
Unintentional injury was the leading cause of death for young people during that same period. Of even more concern, a 2019 United Health Foundation report found that the teen suicide rate increased by 25 percent nationwide from 2016 to 2019 and that California was one of seven states with the most significant increases in teen suicide rates during that same period. Based on the CDC’s high school youth risk behavior survey results, the percentage of high school students nationwide who seriously considered suicide during the previous year increased from 14.5 percent in 2007 to 17.2 percent in 2017, while the percentage of attempted suicides increased from 6.9 percent to 7.4 percent. The increases in these already unacceptably high statistics point to a serious public health problem.
From 2009 through 2018, the annual number of suicides of youth ages 12 to 19 in California increased from 163 to 188 (15 percent), as Figure 1 shows. In addition, self‑harm—which, as the text box defines, is behavior that is self‑directed and that deliberately results in injury—has also increased in recent years. As Figure 2 shows, from 2009 through 2018, the annual number of reported youth self‑harm incidents that led to emergency department visits or hospital stays increased from almost 10,900 to more than 16,300, an increase of 50 percent.
The Number of Youth Suicides in California Increased From 2009 Through 2018
Source: Analysis of Public Health’s vital death data.
Incidents of Youth Self‑Harm Requiring Medical Attention Increased by 50 Percent From 2009 Through 2018
Source: Analysis of hospital encounter data from the Office of Statewide Health Planning and Development.
Note: We explain the methodology we used to create this figure in Appendix A, Objective 2.
Factors That May Contribute to Youth Suicide
There is no single cause for suicide, but researchers report that it occurs most often when stressors and health issues converge to create feelings of hopelessness and despair. Youth are more vulnerable to suicide if they have certain characteristics and experiences, including mental health conditions, previous family suicide attempts, and exposure to prolonged stress, such as from harassment and bullying. Research has also identified youth in specific groups as having an elevated risk for suicide, including those with disabilities, those in foster care, and those who identify as lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ).
Although counties with metropolitan areas have the highest total number of youth suicides, our analysis of data from the California Department of Public Health (Public Health) shows that many of the State’s northern rural counties have higher suicide and self‑harm rates, as Figure 3 and Figure 4 indicate. For example, Sierra County—a northern rural county with a population of less than 10,000—has the highest youth suicide rate in the State, 34 per year per 100,000 for persons ages 10 to 19. This is more than nine times the statewide rate. However, some counties with high suicide rates have a relatively low total number of suicides. For example, the three counties with the highest suicide rates are northern and rural counties that had only seven youth suicides from 2009 through 2018, compared to a total of 1,809 youth suicides statewide.
Many of the State’s Rural and Northern Counties Had Higher Rates of Youth Suicide From 2009 Through 2018
Source: Analysis of Public Health’s vital death data and the U.S. Census Bureau’s American Community Survey 2014 to 2018 five‑year population estimate.
Many of the State’s Rural and Northern Counties Had Higher Rates of Youth Self‑Harm From 2009 Through 2018
Source: Analysis of hospital encounter data from the Office of Statewide Health Planning and Development and the U.S. Census Bureau’s American Community Survey 2014 to 2018 five‑year population estimate.
The higher rate of youth suicide rates in rural counties is likely affected by the availability of mental health professionals, which is generally lower in rural counties. Studies have generally found a positive association between increased access to care and lower suicide rates. However, in many rural communities, economic factors and sparse population density have led to shortages of mental health professionals, according to a report by the Rural Youth Suicide Prevention Workgroup. This workgroup was convened by the federally funded nonprofit Suicide Prevention Resource Center and others.
In addition to varying by urban and rural areas, the rates of suicide and self‑harm vary by gender. Our analysis of Public Health data from 2009 through 2018 found that males ages 12 to 19 years died by suicide at nearly three times the rate of females, as Figure 5 shows. Conversely, females in this same age group committed self‑harm at nearly three times the rate of males. In fact, instances of self‑harm by females increased 64 percent from 2009 to 2018, more than three times the rate of self‑harm by males during the same period.
Incidents of Youth Suicide and Self‑Harm Varied by Gender From 2009 Through 2018
Source: Analysis of Public Health’s vital death data and of the Office of Statewide Health Planning and Development hospital encounter data from 2009 through 2018 for youth aged 12 to 19.
Notes: The available data did not specify gender for fewer than 10 incidents of self‑harm. We did not include these incidents in this figure.
We explain the methodology we used to create this figure in Appendix A, Objective 2.
The Role of Mental Health Services in Suicide Prevention
Research suggests that mental health care is a critical component of suicide prevention. The CDC lists barriers to accessing mental health treatment as one of the risk factors for suicide.
The National Alliance on Mental Illness indicates that barriers to accessing mental health treatment include the cost of mental health care and the difficulty of finding psychiatrists and other mental health care providers. Multiple studies have also identified positive associations between access to mental health care services—such as a higher density of psychiatrists in a given area—and reductions in suicide and in the factors leading to suicide. For example, a 2006 study of U.S. Census Bureau data and medical statistics found lower suicide rates in states with higher densities of psychiatrists, higher federal funding for mental health services, and lower rates of uninsured residents—correlations that the authors concluded support the importance of clinical intervention in preventing suicide. In a 2013 study, researchers found that states that enacted laws requiring that insurance plans cover mental health benefits experienced reduced suicide rates in the following years. Although identifying the exact correlation between mental health services and suicide prevention is an ongoing area of study, the current body of research indicates that increased access to mental health care reduces suicide rates.
California voters recognized the importance of mental health services in suicide prevention when they voted to approve Proposition 63—known as the Mental Health Services Act (MHSA)—in 2004. The MHSA expands services and treatment for children, adults, and seniors who suffer from mental illness or who are at risk of mental illness, in part through its focus on prevention and early intervention programs. The act cited the need to address untreated mental illness that may lead to suicide and concerns that children who are untreated often become unable to learn or participate in school. The MHSA imposes a 1 percent income tax on individuals earning more than $1 million a year and allocates about 95 percent of these funds to local governments. It also established the Mental Health Services Oversight and Accountability Commission (Oversight Commission) to oversee county prevention and innovation programs. In each of the last three fiscal years, the State allocated more than $1.8 billion in MHSA funds to local governments for mental health programs.
Mental Health Services in California Schools
According to Education, schools offer a broad range of mental health services, including the following:
- Academic and personal counseling
- Interventions to address behavior issues
- Crisis intervention
- Assessments and referrals to other services
Education says that providing these services in a school setting helps address barriers to learning and supports student success both in and outside of school.
Source: Education’s website and the Commission on Teacher Credentialing Pupil Personal Services Program Standards.
The Role of Local Educational Agencies in Suicide Prevention Efforts
In academic year 2018–19, California had more than 1,000 school districts, 58 county offices of education, and 1,300 charter schools, known collectively as local educational agencies (LEAs). As the text box shows, LEAs provide different types of mental health services. Some LEAs employ school counselors, school nurses, school social workers, and school psychologists, which we collectively refer to as mental health professionals. Because students spend a significant amount of time in school, the personnel who interact with them every day are in a prime position to recognize the warning signs of suicide and make the appropriate referrals for help. According to the National Association of School Psychologists, youth who are contemplating suicide frequently give warning signs of their distress but are not likely to seek help directly. Thus, training school staff to respond to youth who exhibit warning signs of suicide is imperative. Figure 6 illustrates many of the efforts the Legislature has made to combat youth suicide and self‑harm, including passing a law in 2016 that requires LEAs that serve students in grades 7 to 12 to adopt suicide prevention policies that address certain key topics, such as suicide intervention.
The Legislature Has Made Efforts to Address Youth Suicide and Self‑Harm
Source: Review of state laws.
Historically, state agencies have had a limited role in LEAs’ suicide prevention efforts. State law charges Public Health—whose mission is to advance the health and well‑being of California’s diverse people and communities—with the responsibility of establishing and maintaining the State’s electronic reporting system for violent deaths; and in September 2020 the governor signed a bill requiring Public Health to establish the Office of Suicide Prevention, if funds are appropriated to do so. Moreover, until recently, the role of the California Department of Education (Education) in suicide prevention was to provide specific, limited resources and information to schools. However, when the Legislature required LEAs to adopt suicide prevention policies before the 2017–18 academic year, it also required that Education develop and maintain a model policy to assist the LEAs. Further, in 2018 the Legislature gave Education the task of identifying one or more online programs for LEAs to use when training school staff and students on suicide prevention.
The Department of Health Care Services (Health Care Services) generally does not work directly with LEAs to address youth suicide prevention. LEAs can receive reimbursement for some mental health care services they provide through the State’s Medicaid program: the California Medical Assistance Program (Medi‑Cal). Health Care Services administers Medi‑Cal through an agreement, known as the state plan, with the federal Centers for Medicare and Medicaid Services (CMS). State law requires Health Care Services to oversee a program called the Local Education Agency Medi‑Cal Billing Option Program (billing option program). Through the billing option program, participating LEAs receive federal reimbursement for 50 percent of the costs of certain health‑related services they provide to Medi‑Cal‑eligible students under age 22. In fiscal year 2017–18, the year for which the most recent data concerning the billing option program is available, more than 500 LEAs participated in the program and claimed nearly $134 million in federal reimbursement.
The Role of Local Partners and Organizations in Preventing Youth Suicides
A variety of organizations focus on suicide prevention and assist schools with their suicide prevention policies. For example, the Trevor Project, a national organization providing suicide prevention and crisis intervention services to LGBTQ people under age 25, cooperated with a number of tax‑exempt organizations to create and publish a model policy for schools with procedures to assess the risk of, prevent, intervene, and respond to suicide. Another suicide prevention organization, the HEARD Alliance, a community alliance of health care professionals located in the San Francisco Bay Area, works to increase collaboration among primary care, mental health care, and education professionals to enhance the community’s ability to prevent suicide in adolescents and young adults, among other things. In 2013 it created a toolkit designed to support school communities—including parents, teachers, school personnel, counselors, and health providers—in preventing youth suicide, and in 2017 it updated this toolkit to reflect legislative requirements enacted in 2016.
In addition, LEAs sometimes partner with community‑based organizations to provide mental health and counseling services to their student populations. Some LEAs also partner with community‑based organizations to provide services on‑site, including mental health assessments, individual counseling sessions, and crisis counseling. LEAs may also refer at‑risk students to off‑site community‑based mental health services.
To assess suicide prevention at the local level, we reviewed the efforts of six LEAs across the State. We selected three counties based on their geography and their rates of youth suicide and self‑harm. We then chose one school district and one charter school within each of these three counties. In Mendocino County, we selected Ukiah Unified School District (Ukiah Unified) and Charter Academy of the Redwoods (Redwoods Charter); in San Francisco County, we selected San Francisco Unified School District (San Francisco Unified) and Gateway Public Schools (Gateway Charter), and in Kern County, we selected Kern High School District and Heartland Charter School (Heartland Charter). We selected Heartland Charter because it conducts much of its instruction via distance learning, a method of instruction that has become increasingly common as LEAs adapt to the COVID‑19 pandemic.