Appraising Evidence: Youth Suicide Experiences and Perceptions Report

This research article presents a qualitative systematic review of experiences and perceptions of youth suicide. The study analyzed 27 articles, focusing on factors leading to suicide attempts, elements important to recovery, community beliefs, and treatment/prevention strategies. Thematic analysis revealed four categories: triggers and risks, factors in recovery, institutional strategies, and community beliefs. The first category was further divided into behaviors, feelings/emotions, family, peer influences, and others. The second category included interpersonal, cultural, and individual influences. The third category was split into education and treatment. The review emphasizes the complexity of youth suicide, highlighting the need for procedural reform and a shift in societal attitudes for successful prevention and treatment.

RESEARCH ARTICLE
A qualitative systematic review of experiences
and perceptions of youth suicide
Jessica Grimmond1, Rachel KornhaberID
1, Denis VisentinID
2, Michelle Cleary1*
1 School of Nursing, College of Health and Medicine, University of Tasmania, Sydney, NSW, Australia,
2 School of Health Sciences, College of Health and Medicine, University of Tasmania, Sydney, NSW,
Australia
* [e-mail]
Abstract
Background
Suicide remains a global issue with over 800,000 people dying from suicide every year.
Youth suicide is especially serious due to the years of life lost when a young person takes
their own life. Social interactions, perceived support, genetic predisposition and mental ill-
nesses are factors associated with suicide ideation.
Objectives
To review and synthesize qualitative studies that explored the experiences and perceptions
of suicide in people 25 years old and younger.
Design
Qualitative systematic review.
Data sources
PubMed, PsycINFO, Scopus and CINAHL were searched alongside hand-searching refer-
ence lists up to October 2018.
Methods
Methodological quality was assessed using the qualitative Critical Appraisal Skills Pro-
gramme checklist. The 27 studies included in the review centered around youth suicide and
included interviews with young people and members of the wider community. Thematic syn-
thesis focused on factors leading to suicide attempts, elements important to recovery,
beliefs within the community, and treatment/prevention strategies.
Results
Thematic analysis of the articles revealed four categories: i) triggers and risks leading to sui-
cidality; ii) factors involved in recovery; iii) need for institutional treatment/prevention strate-
gies; and iv) beliefs about suicide at a community level. The first category was further
subdivided into: i) behaviours; ii) feelings/emotions; iii) family influences; iv) peer influences;
PLOS ONE | https://doi.org/10.1371/journal.pone.0217568 June 12, 2019 1 / 25
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OPEN ACCESS
Citation: Grimmond J, Kornhaber R, Visentin D,
Cleary M (2019) A qualitative systematic review of
experiences and perceptions of youth suicide.
PLoS ONE 14(6): e0217568. https://doi.org/
10.1371/journal.pone.0217568
Editor: Soraya Seedat, Stellenbosch University,
SOUTH AFRICA
Received: January 7, 2019
Accepted: May 14, 2019
Published: June 12, 2019
Copyright:© 2019 Grimmond et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
Information files.
Funding: This work was supported by the
University of Tasmania (AU) Summer Scholarship
Scheme to JG. The funder had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.

and v) other. The second category was split into: i) interpersonal; ii) cultural; and iii) individ-
ual influences, while the third category was divided into i) education; and ii) treatment.
Conclusion
Youth suicide is a complex issue with many causes and risks factors which interact with one
another. For successful treatment and prevention, procedural reform is needed, along with
a shift in societal attitudes toward emotional expression and suicide.
Introduction
Suicide impacts the lives of many people across the globe and is a concerning pub
issue [1]. Almost 800,000 people’s deaths are the result of suicide internationally e
accounting for 1.4% of all deaths [2]. The incidence of suicidal ideation universally
during adolescence [3], with suicide the second leading cause of death worldwide
29 years age group [2]. Hence the impact of suicide on the families and communit
cant. Since the proportion of suicide deaths among young people is high, youth su
be considered a serious health issue due to the broader social cost and the years o
when a young person takes their own life.
A number of theoretical models provide a framework for understanding the com
action between biopsychosocial influences on suicidality. While each of these mod
a different explanation and emphasises different specifics, there are similarities th
The Interpersonal Theory of suicide (IT) [4], the Integrated Motivational-Volitional M
suicidal behaviour (IMV) [5] and the Three-Step Theory (3ST) [6] each separate sui
tion from actual attempts and explore the differences between suicidal thoughts a
actions. While the IT was developed to provide a comprehensible and potentially fa
framework of suicidality [4], the IMV model was borne out of a need to predict fact
influence suicide ideation and the circumstances whereby these thoughts are acte
Similar to the IT, the 3ST is a demonstration of what Klonsky and May call an “idea
action" framework [7] based in empirical evidence [6], though it emphasises differ
Each of these models provides a detailed perspective of the cognitive, social and p
contributors to suicidal ideation and attempts.
Psychological factors and personality differences such as hopelessness, impulsiv
resilience all have a bearing on a person’s likelihood of experiencing suicidal ideat
Hence, identifying and understanding these factors is an important step in predicti
venting suicide. The first step in the 3ST centres around experiences of hopelessne
which are usually, but not exclusively, emotional. [6]. They posit that frequent exp
pain act as punishment, resulting in the individual “essentially being punished for
but that pain must also be coupled with psychological experiences of hopelessness
cal data supports this, as both pain and hopelessness were strongly related to suic
and with one another [6]. While this theory is not specific to young people, the res
consistent in the youth age bracket [6].
The IT also highlights the importance of psychological experiences. A key eleme
is the perception of burdensomeness whereby low self-esteem and feelings of expe
(among others) contribute to dimensions of self-hate and liability [4]. These dimen
bine to result in perceived burdensomeness [4]. The IT suggests that when perceiv
someness is coupled with barriers to socialisation, and these are viewed as ‘stable
Experiences and perceptions of youth suicide
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permanent’ [4] states, suicidal ideation may occur. These barriers to socialisation a
‘thwarted belongness’ and include feelings of loneliness and a lack of reciprocal ca
this way, the IT provides a dynamic explanation of suicidal ideation as it considers
logical influences in conjunction with social ones [4].
Other theoretical frameworks also consider social factors to have a strong influe
cidality. In the second phase of the IMV model, the motivational phase, feelings of
humiliation can progress to those of entrapment when threats to self-moderators,
inability to adequately resolve social problems, exist [5]. Like the IT, the IMV mode
thwarted belongingness to be an important social factor and, here, it acts as a mot
moderator which sees feelings of entrapment develop into suicidal ideation [5]. Re
ports this model suggesting those who are more sensitive to the social judgements
more likely to feel defeat and entrapment, which are central to the motivational ph
IMV model [5].
Socialisation is also considered a factor in the 3ST. The second step in this theor
connectedness which usually describes interpersonal relationships, but can also be
include an attachment to work or hobby interests [6]. In this model, connectednes
against progression from moderate to severe ideation [6]. In this way, the 3ST diffe
IT, as it acknowledges factors which can stem progression [6], where the IT focuse
tive factors alone [4]. In the 3ST, the psychological experiences of pain and hopele
lead to suicidal ideation, but only when these feelings are combined with a disrupt
nectedness is it possible for a person to move from ideation to suicide attempt [6].
Klonsky and May [6] suggest that social influences play a vital role in suicide.
In line with these theoretical models, difficulty with socialisation and interperson
have been identified as predictors of suicidality in adolescents [1]. The death of a l
been linked to suicidality in adolescents [1, 3] and research has identified that ado
have been exposed to suicide and related behaviours were far more likely to self-r
related behaviours [8]. The causes for this link, however, are unclear. Experiencing
of a family member may offer a behavioural model for young people who are alrea
ble [1, 5] or it may simply make it more salient in a young person’s mind as a solut
problem [5].
In a similar way, the presence of ‘cluster effects’ and the concept of peer contag
lights the important role of socialisation, especially in adolescents [9]. However, sin
causes of these phenomena are poorly understood, misconceptions about the soci
sion of suicide exist within society. The belief that incidents of suicide become high
ideation and related behaviours are discussed is common and has informed public
These beliefs, however, are not based in empirical evidence [10]. Nonetheless, the
effects’ do exist, and adolescence seems to be the peak time for peer contagion an
ence [9].
One explanation for these cluster effects is that people are more attracted to tho
perceive as being similar to themselves [11]. The group will likely experience simil
and events [1] and an adolescent’s experience of depression can be well predicted
their friends [9]. Therefore, rather than a ‘copycat’ explanation of suicide, it is reas
assume that some of the factors contributing to suicidal ideation in one person wil
affecting that person’s peers [9]. In fact, experiencing a peer’s suicide, itself, may
of hopelessness and thwarted belongingness which are linked with suicidal ideatio
cussed theoretical models [4, 6].
The acceptance of suicide as an appropriate response to negative life events ma
become normalised as a shared belief between members of social groups or certai
[12, 13]. In this way, attitudes and understanding become shaped by the experien
Experiences and perceptions of youth suicide
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beliefs of others [12]. It is also important to consider, however, that those with pre
nerabilities may be drawn to likeminded people or subcultures (eg. Goth or EMO) f
outset, which will bias the sample and overemphasise the social influences on suic
13].
When considering the social impact that a family member’s suicide may have, it
ble to separate the possible predisposition to psychiatric disorders associated with
[1]. Autopsies indicate a prevalence of psychiatric disorders of over 90% in those w
died by suicide, though these are not always diagnosed while the person is alive [3
history of mental health problems or suicide can also be a predictor of suicidality [
though the genetic influence is unclear.
These biological influences are also well explained in the current theoretical mod
explains that for a person to progress from ideation to attempt, they must acquire
ity for suicide [4]. This capability can be acquired cognitively, through a reduced fe
or physically through increased pain tolerance [4]. Similarly, the 3ST acknowledge
pain sensitivity can provide a dispositional capacity for suicide, while it can also be
through repeated exposure socially or through practical access to means [6]. It is c
these models that physiology has a part to play in suicidality, but that both suicida
and suicide attempts involve a complex combination of biopsychosocial factors.
Since there are so many influences on suicidality, identifying them and exploring
tionships to one another is an important step in prevention and treatment approac
also important to consider that, while the current models of suicide provide a stron
work of the issue, they are not age specific. Since the experiences of adolescents w
greatly from those further into adulthood, research that centres on young people i
[3]. While information gathered from quantitative studies is important in assessing
aspects of youth suicide, detailed thematic analysis of qualitative data [14] can pro
and specific insights into the thoughts and feelings of those directly affected, as w
wider community.
The need to explore societal perceptions of suicide has been identified [3] and t
compare these views with the lived experience of suicidal young people, for examp
vide a deeper understanding of the issue. Hawton, Saunders and O’Connor [1] hav
gested that future research should explore the factors that assist in moving away f
suicidality. While various studies focus on specific aspects of suicide such as preve
gies [15, 16], psychiatric factors [17], and treatment strategies, there is a need for
which takes a more macro approach. Therefore, this review focuses on the suicida
of young people and explores not just the experiences of suicidal people, but inclu
ions of health professionals, parents and members of the wider community in orde
the true complexity of the issue.
Objective of the review
To review and synthesize qualitative studies that explored experiences and percep
cide in people 25 years old and younger.
Methods
This qualitative systematic review was guided by the thematic synthesis methodol
Thomas and Harden [14] with reporting meeting the Enhancing Transparency in Re
the Synthesis of Qualitative research statement (ENTREQ) consisting of 21 reporte
Table) [18].
Experiences and perceptions of youth suicide
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Inclusion and exclusion criteria
Included studies met the following criteria: i) original qualitative studies published
reviewed journals in the English language with no date restriction; ii) participants w
adolescents or young adults (25 years of age or younger) who had attempted suici
family members of those who had attempted suicide or experienced suicidal ideati
sionals working with young people or members of the wider community; iii) qualita
views primarily discussing youth suicide and suicidal ideation in young people. Exc
studies were abstracts, editorials, conference proceedings, theses, and secondary
sources (e.g. reviews). Studies which were quantitative were excluded.
Search strategy
A comprehensive literature search was conducted up until October 2018 without ti
(by RK, MC) using four electronic databases: PubMed, Scopus, Cumulative Index of
and Allied Health Literature (CINAHL), and PsycINFO. Boolean connectors AND and
were used to combine the following MeSH and search terms: adolescen�
, teenager�
, suicidal
ideation, suicide, attempted suicide, trigger�
, risk factors, perception�and qualitative research.
As each database uses different indexed terms, the search strategy was adapted f
in syntax and indexed/MeSH terms for each database (S2 Table).
Title and abstract screening of all papers identified by the search strategy was in
performed by authors MC, RK and JG with reference to the published inclusion/excl
criteria.
Search outcome
A total of 617 studies were identified. Following removal of 160 duplicates, 457 titl
abstracts were then screened of which 406 did not meet the inclusion criteria. Fifty
text articles were therefore retrieved and screened for eligibility and 31 were exclu
of the reference lists of the remaining studies identified 7 further studies meeting
criteria. In total, 27 qualitative studies met the inclusion criteria for this systematic
study selection process is detailed in the PRISMA Flow Diagram [19] (Fig 1).
Quality appraisal
Quality appraisal of studies meeting the inclusion criteria was conducted by three
the research team (MC, RK and JG) using the Critical Appraisal Skills Programme fo
tive Studies Checklist [20]. All 27 qualitative studies identified were included (Tabl
Characteristics of studies
The studies included in this review ranged in size from a case study of one individu
134 participants [22] with an average of approximately 38 participants, though no
disclosed exact numbers. At least five studies involved Caucasian participants [21,
included Native American populations [27–30] while four involved Hispanic and Lat
ticipants [23, 31–33]. At least one study each focused on participants from Nicarag
Korea [22], Iran [35], Italy [36] and Cambodia [37], while other studies referenced
participants from a variety of ethnic backgrounds [38, 39]. In all studies which prov
gender of participants, there were more female participants, except one which had
sentation of gender [36]. Five included studies reported only female participants [2
Participants who attempted suicide ranged in age from 11 to 28 years and had exp
cidal ideation or attempted suicide at 25 years of age or younger. Studies which in
Experiences and perceptions of youth suicide
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Fig 1.PRISMA flow chart search strategy.
https://doi.org/10.1371/journal.pone.0217568.g001
Experiences and perceptions of youth suicide
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Table 1.CASP ratings.
Authors and year of
publication
Bergmans,
Langley, Links,
and Lavery
(2009)
Bostik and
Everall (2007)
Coggan,
Patterson, and
Fill (1997)
Everall, Bostik,
and Paulson
(2005)
Everall, Bostik,
and Paulson
(2006)
Fullagar,
Gilchrist, and
Sullivan (2007)
Gulbas,
Hausmann-
Stabile, De Luca,
Tyler, and Zayas
(2015)
CASP Question Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No
Are the aims stated clearly?● ● ● ● ● ● ●
Is the qualitative
methodology appropriate
● ● ● ● ● ● ●
Is the research design
appropriate to address aims
of the research
● ● ● ● ● ● ●
Recruitment strategy
appropriate to aims?
● ● ● ● ● ● ●
Does the data collection
method addressed research
issue?
● ● ● ● ● ● ●
Has relationship between
researcher and participants
been considered?
● ● ● ● ● ● ●
Have ethical issues taken
into consideration?
● ● ● ● ● ● ●
Was the data analysis
sufficiently rigorous?
● ● ● ● ● ● ●
Is there clear statement of
findings?
● ● ● ● ● ● ●
How valuable is the
research?
● ● ● ● ● ● ●
https://doi.org/10.1371/journal.pone.0217568.t001
Table 2.CASP ratings.
Authors and year of publicationGulbas and Zayas
(2015)
Herrera,
Dahlblom,
Dahlgren, and
Kullgren (2006)
Holliday and
Vandermause
(2015)
Jegannathan,
Kullgren, and
Dahlblom (2016)
Jo, An, and Sohn
(2011)
Keyvanara and
Haghshenas
(2011)
CASP Question Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No
Are the aims stated clearly? ● ● ● ● ● ●
Is the qualitative methodology
appropriate
● ● ● ● ● ●
Is the research design appropriate to
address aims of the research
● ● ● ● ● ●
Recruitment strategy appropriate to aims?● ● ● ● ● ●
Does the data collection method
addressed research issue?
● ● ● ● ● ●
Has relationship between researcher and
participants been considered?
● ● ● ● ● ●
Have ethical issues taken into
consideration?
● ● ● ● ● ●
Was the data analysis sufficiently
rigorous?
● ● ● ● ● ●
Is there clear statement of findings?● ● ● ● ● ●
How valuable is the research? ● ● ● ● ● ●
https://doi.org/10.1371/journal.pone.0217568.t002
Experiences and perceptions of youth suicide
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from other members of the community included participants aged up to 64 years o
studies involved data from young people who had experienced suicidal ideation an
additionally provided their parent/caregiver’s testimony [32, 40, 41]. Some studies
data from members of the wider community and their thoughts about youth suicid
28, 30, 37, 39, 42] or those who worked with [43] or knew [44] a young person wh
attempted suicide. At least three of the included studies took place in schools [37,
while others included interviews in treatment facilities [36, 40, 43] and post-discha
Table 5 presents a summary of included studies.
Data extraction and synthesis
Researcher JG in collaboration with other team members (MC, RK) led the data ext
and synthesis of these studies. Key themes were compiled for each article and the
were then grouped based on common traits. In line with Thomas and Harden’s [14
for thematic synthesis, the ‘Results’ section of each article was analysed using line
ing. Each category was designated a colour and the sub-categories within each the
resented by a number. Text that was relevant was highlighted in the theme’s corre
colour and the number of the subtheme written adjacent. Coloured tabs were used
page to ensure each piece of relevant text could be quickly and appropriately acce
ther analysis. Upon completion of the line-by-line coding, each subtheme was re-ex
and each piece of text compared to others in that category for similarities and diffe
findings were then reviewed by all team members and synthesised.
Table 3.CASP ratings.
Authors and year of
publication
Matel-Anderson
and Bekhet
(2016)
Montreuil,
Butler, Stachura,
and Gros (2015)
Orri et al. (2014)Roen, Scourfield,
and McDermott
(2008)
Schwartz, Pyle,
Dowd, and
Sheehan (2010)
Shilubane,
Ruiter, Bos,
Reddy, and Van
Den Borne
(2014)
Shilubane et al.
(2012)
CASP Question Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No
Are the aims stated clearly?● ● ● ● ● ● ●
Is the qualitative
methodology appropriate
● ● ● ● ● ● ●
Is the research design
appropriate to address aims
of the research
● ● ● ● ● ● ●
Recruitment strategy
appropriate to aims?
● ● ● ● ● ● ●
Does the data collection
method addressed research
issue?
● ● ● ● ● ● ●
Has relationship between
researcher and participants
been considered?
● ● ● ● ● ● ●
Have ethical issues taken
into consideration?
● ● ● ● ● ● ●
Was the data analysis
sufficiently rigorous?
● ● ● ● ● ● ●
Is there clear statement of
findings?
● ● ● ● ● ● ●
How valuable is the
research?
● ● ● ● ● ● ●
https://doi.org/10.1371/journal.pone.0217568.t003
Experiences and perceptions of youth suicide
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Results of the review
Thematic analysis of the articles revealed four categories: i) triggers and risks lead
ality; ii) factors involved in recovery; iii) need for institutional treatment/prevention
iv) beliefs about suicide at a community level (Table 6). The first category, triggers
leading to suicidality was further subdivided into: i) behaviours; ii) feelings/emotion
ily influences; iv) peer influences; and v) other. The second category, factors involv
ery was further divided into: i) interpersonal; ii) cultural; and iii) individual influenc
the need for institutional treatment/prevention strategies category is split into i) ed
and ii) treatment subcategories.
Triggers and risks leading to suicidality
Behaviours.The most commonly displayed behaviour was difficulty with commun
tion, specifically with communicating personal feelings [25, 38]. This was in part a
participant age with many younger people lacking the “vocabulary to talk about fe
instead relying on cliche´s and metaphors which inadequately expressed their true emot
[25, 29]. For others, communication issues stemmed from emotional barriers due t
tionships [32, 34] including mistrust of those around them [30]. When communicat
attempted, disclosure to friends and family can be difficult for the suicidal person,
receives little sympathy or tough love [32, 34, 36, 39, 42]. In addition, their confida
Table 4.CASP ratings.
Authors and year of
publication
Strickland and
Cooper (2011)
Strickland,
Walsh, and
Cooper (2006)
Sukhawaha,
Arunpongpaisal
&
Rungreangkulkij
(2016)
Tingey et al.
(2014)
Walls, Hautala,
and Hurley
(2014)
White and
Morris (2010)
Zayas, Gulbas,
Fedoravicius, and
Cabassa (2010)
CASP Question Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No Yes Can’t
tell
No
Are the aims stated clearly?● ● ● ● ● ● ●
Is the qualitative
methodology appropriate
● ● ● ● ● ● ●
Is the research design
appropriate to address aims
of the research
● ● ● ● ● ● ●
Recruitment strategy
appropriate to aims?
● ● ● ● ● ● ●
Does the data collection
method addressed research
issue?
● ● ● ● ● ● ●
Has relationship between
researcher and participants
been considered?
● ● ● ● ● ● ●
Have ethical issues taken
into consideration?
● ● ● ● ● ● ●
Was the data analysis
sufficiently rigorous?
● ● ● ● ● ● ●
Is there clear statement of
findings?
● ● ● ● ● ● ●
How valuable is the
research?
● ● ● ● ● ● ●
https://doi.org/10.1371/journal.pone.0217568.t004
Experiences and perceptions of youth suicide
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Table 5.Summary of included studies (n = 27).
Author/s, year &
country
Aims Sample & study population Methods Findings
Bergmans, et al.
[47], 2009, Canada
To understand the transition to safer
behaviours and to provide clinical
suggestions to those who provide care
to this population.
Sixteen people aged 18–25 years
with a history of two or more
suicide attempts.
Qualitative, grounded
theory study
A pathway from high to lower risk was
established. Young people at the
highest risk of attempting suicide
spoke about “Living to Die” and
progressed through “Ambivalence and
Turning Points” to “Pockets of
Recovery” as they move aware away
from suicidality.
Bostik and Everall
[24], 2007, Canada
To develop an understanding of
adolescent’s perceptions of the role of
attachment relationships in the
process of overcoming suicidality.
Fifty adolescents who were
previously suicidal between the
ages of 13 and 19 years old.
Qualitative interviews,
grounded theory study
Parents, peers and extra-familiar
adults each had important attachment
relationships with young people
recovering from suicidal ideation as
did a spiritual connection. Finding
acceptance, having a permanent
relationship, receiving encouragement
and experiencing intimacy and
closeness were all common
experiences of attachment. These
attachment relationships and
experiences helped young people
change their self-perceptions.
Coggan, et al. [42],
1997, New Zealand
To enhance knowledge of ways to
address youth suicide.
School age students Focus groups and analysisStudents spoke about what they
believed the warning signs of a suicidal
friend, their perceptions of available
services and resources for young
people at risk and potential prevention
strategies.
Everall, et al. [21],
2005, Canada
To illustrate the role developmental
processes, cognitive development,
identity formation and autonomy
seeking played in one teenager’s
experience of becoming and
overcoming being suicidal.
One 20-year-old female Case study The participant spoke about factors
which contributed to her becoming
suicidal and those that were important
in overcoming suicidality.
Everall, et al. [25],
2006 Canada
To explore how adolescents and
emerging adults conceive their
emotional experiences associated with
being suicidal.
Forty-one females, nine males
previously suicidal between the
ages of 14–24
Qualitative interviews,
grounded theory approach
Participants spoke of the
overwhelming despair, shame and self-
loathing, and alienation and isolation
they experienced. They also spoke of
how they responded to these emotions
and how they moved beyond
suicidality.
Fullagar, et al.
[26], 2007,
Australia
To explore how everyday
understandings of the issues
surrounding suicide risk and
prevention were constructed within
community contexts and were
mediate by a range of social
institutions.
Eighty-one young people (aged
15–24 years), service providers
(teachers, school counselors,
sports coaches and youth and
health workers) and adults
(parents and community leaders)
Structured interviews
including 10 open ended
questions
Constructions of suicide through
statistics and stories were common, as
was discussion about stigma and
distancing of suicide. Young people
and adults also differed on their
perspectives of youth suicide.
Gulbas, et al. [31],
2015, USA
To describe and compare the
conditions and experiences that
precede the decisions to self-harm in
order to contribute to an
understanding of the contexts
surrounding self-harmful behaviours
within in Latina adolescent behaviour.
Thirty-seven Latinas between the
ages 11–19 who attempted suicide
through self-harm.
Qualitative interviews and
analysis
Attempters spoke about feeling
powerless, as well as unloved and
unsupported in their interpersonal
relationships. A history of self-harm
was also common.
Gulbas and Zayas
[32], 2015, USA
To link the attempters experience to
the broader socio-cultural forces that
the attempters both encounters and
surrenders to.
Ten Latina teen suicide attempters
and their parents
Qualitative interviews and
comparative analysis
Participants reported subjective
distress, interpersonal discord and
emotional isolation.
(Continued )
Experiences and perceptions of youth suicide
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Table 5.(Continued)
Author/s, year &
country
Aims Sample & study population Methods Findings
Herrera, et al.
[34], 2006,
Nicaragua
To explore perceived causes and
discover triggers and processes
leading to suicidal behaviour among
adolescent girls in Leon, Nicaragua.
Eight Nicaraguan girls aged
between 12–19 admitted to
hospital after attempting suicide
In-depth interviews,
grounded theory and
content analysis
Perceived causes were material
conditions, family structure and
norms and values. When combined
with triggering events and emotions
these conditions elicit action from the
participants. These actions were
explained as problem solving, escape
or suicide attempt.
Holliday and
Vandermause
[38], 2015, USA
To describe and interpret the
phenomenon of attempted suicide in a
sample of teens who visit an
emergency department for a suicide
attempt
Six young people aged 15–19 who
visited an emergency department
for a suicide attempt
Heideggerian hermeneutic
methodological approach
Common patterns and themes were
identified. The pattern of attempting
as a way of communication was
evident through themes of Ambiguity
and cries of pain. The second pattern,
attempting as transforming is
described through being unconnected,
spiraling down and being alone with
suffering. Conversely, connecting was
seen as a way to climb upwards.
Jegannathan, et al.
[37], 2016,
Cambodia
To explore the views of the focus
group on the societal attitudes towards
suicide, contemporary media norms,
Buddhism and their influence on
suicidal behaviour
Forty-eight students from 2
schools in Cambodia
Focus groups and thematic
analysis
The social stigma of suicide was a
common theme throughout, as was the
double-edged nature of the media as
both educative and suicide-
provocative. Suicide-ambiguity in
Buddhism was also prevalent.
Jo, et al. [22],
2011, Korea
To understand the suicidal ideation of
the qualitative content analysis in
South Korean college students
One hundred and thirty-four
South Korean college students
Non-structured open
questions, qualitative
content analysis
Physical, physiological and social
concerns were discussed as being
facilitators of suicidal ideation, while
religious, individual and relational
beliefs were seen as inhibitors.
Keyvanara and
Haghshenas [35],
2011, Iran
To illuminate the socio-cultural
context of attempted suicide among
Iranian youth.
Twenty-five young people aged
14–17 who attempted suicide and
were admitted to hospital in
Isfahan
Qualitative interviews,
thematic analysis
Participants frequently reported
despair, failure in love, family issues
involving conflicts between children
and their parents and/or siblings, the
pressure of high expectations from
family and peers, and poverty as
important factors in their suicide
attempt.
Matel-Anderson
and Bekhet [43],
2016, USA
To explore components of resilience
in adolescents who survived a suicide
attempt from the perspective of nine
psychiatric nurses.
Nine psychiatric nurses. Focus group and analysisRisk factors were split into six
categories: Unstable households and
traumatized childhood history, having
a means to drugs and firearms,
bullying, cognitive distortions and lack
of vision for the future, absence of
parental bonding and lack of positive
role model, and poor self-esteem and
issues with identity.
(Continued )
Experiences and perceptions of youth suicide
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Table 5.(Continued)
Author/s, year &
country
Aims Sample & study population Methods Findings
Montreuil, et al.
[40], 2015, Canada
To find what the perceptions of
children with suicide associated risk
factors and their parents are regarding
helpful nursing care in pediatric
mental health settings?
Children with at least one suicide
risk factor and their psychiatric
problem, and their parents
Semi-structured
interviews, participant
observation and inductive
analysis
Caring for the child as a special person
was considered important in recovery.
Ways of doing this included getting to
know the child, personalizing care,
being available, and communicating
calmly. Caring for parents was
achieved through being available to
parents and reassuring parents
through talking. Managing the child’s
illness involved including parents in
the care team, linking the body to the
thinking and teaching coping
behaviours. It was also important to
create a therapeutic environment by
managing the physical and social
environments.
Orri, et al. [36],
2014, Italy
To explore the perspective of
adolescents directly involved in
suicidal acts
Sixteen adolescents with either
single or multiple suicidal acts in
their past or with a history of.
Qualitative interviews and
interpretive
phenomenological analysis
Common themes were divided into
individual and relational dimensions
of the suicide attempt. Individual
dimensions included negative
emotions toward the self and the need
to have control over their lives.
Relational dimensions involved a
perceived impasse in interpersonal
relationships, communication issues,
and suicide as revenge.
Roen, et al. [39],
2008, UK
To consider how some young people
become positioned as suicidal subjects
while others do not and how some
young people find suicidal behaviour
imaginable while others do not
Sixty-nine people aged 16–24
years
Interviews and focus
groups, discourse analysis
Common themes for discussion
involved the ‘othering’ of suicide,
suicidal subjecthood as being readily
accessible and attempts to rationalize
why people attempt suicide.
Schwartz, et al.
[23], 2010, USA
To understand the attitudes, beliefs
and perceptions of adolescents and
parents of adolescents from a variety
of backgrounds regarding adolescent
suicide
Ninety-six children of 13–18 years
of age and parents/guardians of
children aged 13–18 years
Semi-structured focus
groups, analysis
Participants spoke about the risk
factors, predictability, preventability
and environmental factors of suicide
in young people,
Shilubane, et al.
[46], 2012, South
Africa
To identify psycho-social target points
for future educational interventions
Fourteen adolescents who
recently attempted suicide
One-on-one in-depth
interviews, analysis
Psychosocial factors identified in this
study were disturbed family
relationships and perceived
accusations of negative behaviour.
Problems with social support systems,
such as family and peer problems, and
experiences of negative emotions and
depression were also prevalent.
Participants discussed negative life
events, often a family history of
suicide, peer suicide or the individual’s
previous suicide attempts, as well as
the impact of living circumstances and
a lack of knowledge of available
counsellors.
Shilubane, et al.
[44], 2012, South
Africa
To describe the impact on high school
students of a suicide or suicide
attempt by a peer to assess students’
knowledge about suicide, perceived
risk factors, signs of poor mental
health, and to assess their awareness of
available mental health care and
resources and opinions on prevention
Fifty-six high school student who
had a peer commit or attempt
suicide
Focus groups, inductive
analysis
Peer reactions were discussed, as were
the signs of poor mental health, the
perceived cause of the peer’s suicide
attempt/suicide, perceived availability
of resources and opinions on
prevention.
(Continued )
Experiences and perceptions of youth suicide
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Table 5.(Continued)
Author/s, year &
country
Aims Sample & study population Methods Findings
Strickland and
Cooper [27], 2011,
USA
To gain an understanding of the
moving processes and stories from the
view of youth by focusing on the
experiences of ‘at-risk’ Indian youth
residing in a Pacific Northwest tribe.
Thirty ‘At-risk’ American Indian
youth aged between 14 and 19
years old residing in a Pacific
Northwest tribe.
Focus groups and
observation, content
analysis
Participants spoke of the effects that
getting into trouble could have and
ways of dealing with the trouble and
coping with the stress. Staying on track
was also considered an important
focus for at-risk youth.
Strickland, et al.
[28], 2006, USA
To gain parents and elders
perspectives on community needs and
to identify strengths on which the
community might build to reduce
suicide
Forty-nine American Indian
parents and elders
Focus groups, content
analysis
Discussions centred around a loss of
culture and tradition, and a
breakdown of family values.
Participants also considered that a
connection to culture and community
can protect against suicidality.
Sukhawaha, et al.
[41], 2016,
Thailand
To understand and describe the
triggering factors associated with
suicidal attempts in adolescence from
the perspective of adolescents who had
direct experience with suicidal attempt
by exploratory descriptive study.
Eighteen adolescents who had
attempted suicide and some of
their parents.
In-depth interviews,
content analysis
Triggering factors included severe
verbal criticism, unwanted
pregnancies and mental illness causing
intense emotions and irresistible
impulses.
Tingey, et al. [29],
2014, USA
To develop the Apache conceptual
model of youth suicide with
qualitative data from a community-
based sample of Apache adolescents
who have attempted suicide.
Twenty-two native adolescents
who had attempted suicide
Longitudinal interviews,
qualitative descriptive
approach
Individual factors contributing to
suicide involved emotion recognitions
and dysregulation, and impulsivity and
reactivity. Family factors included
family dynamics, household
composition, substance use and family
support. Community factors involved
grief burden, and stigma, while societal
factors were imitation and minimizing
the significance of youth suicide after
the fact.
Walls, et al. [30],
2014, Canada
To share the voices of adult
community members from a single
cultural group across 3 separate
central Canadian first nations reserves
who participated in focus group
discussions about the devastating loss
of their young people to suicide.
Elders and service providers Qualitative interviews,
thematic analysis
Participants spoke of interpersonal
factors such as the presence of suicide
clusters/normalization of suicidality,
barriers to communication and
relationships/early dating. Meso-level
factors included family and
community factors. Family factors
involved the parental abuse of alcohol
and drugs, gambling and poor
parenting skills. Macro-level factors
such as historical trauma, the effects of
European contact and residential
school systems, loss of identity and the
need to return to the traditional way of
life were all discussed in these focus
groups.
White and Morris
[45], 2010, Canada
To document the planning and
implantation of a four-part,
classroom-based suicide prevention
education program within one
secondary school as a way to better
understand how it is conceptualized
and experienced.
Two grade 11 English classrooms
scheduled to receive a suicide
prevention curriculum
In-depth case study
discursive critical
constructionist
methodology
Depression and mental illness, stress,
uncertainty, multiplicity and
unpredictability were all common
perceptions of youth suicide. It was
also observed that children often
learned things which were not actively
taught and the role this may play in
planning education programs.
Zayas, et al. [33],
2010, USA
To explore what the conditions in
which suicide attempts occur among
young Latinas, how Latinas experience
the circumstances that led to the
attempt and what young women say
precipitated their suicide attempts and
what triggers the act.
Twenty-seven teenage Latinas
aged 11–19 living in New York
City who had attempted suicide
Qualitative interviews,
thematic analysis
Participants varied in why they
attempted suicide and patterns of
distress involving escalating tensions
and a trigger were prevalent. These
teenagers also spoke about their
reactions, regrets and insights
following their attempts.
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Table 6.Summary of key findings.
Categories Sub-Categories Themes
Triggers and Risks Leading to Suicidality Behaviours Risk taking/Impulsivity
Self-Harm
Lack of Future Orientation
Mood Swings
Communication Difficulty
Feelings/Emotions Lack of Control/ Powerlessness
Ambivalence Toward Death
Isolation
Anger/Aggression
Self-Esteem Issues
Appeal of Death
Family Influences Difficult Family Relationships
Poor Living Conditions
Family Violence
Death of a Loved One
Peer Influences Difficult Peer Relationships
Academic Challenges
Failure in Love
Other Previous Experience with Suicide
Cultural Challenges
Drugs/Alcohol Use
Factors Involved in Recovery Interpersonal Formation/Improvement of Relationships
Supportive Families
Changing/Managing Environment
Cultural Building Cultural/Family Values
Spirituality
Community Factors
Individual Improved Self-Esteem
Learning About Feelings and Life
Finding Future Orientation
Need for Institutional Treatment/Prevention StrategiesEducation Education in Schools
Youth-Specific Initiatives
Information Initiatives
Specialised Support/Education for Parents
Treatment Professional Help (e.g. Counselling, help lines, psychologists etc.)
Treating the Whole Person
Better Assessment
An Holistic Approach to the mind/body
Realistic Discharge Expectations
Beliefs About Suicide Within the Wider Community Social Stigma
Gender/Racial Differences
Desire to rationalize ‘Why’
It is Common
Media Representations of suicide
Relationship with Mental Illness
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compromised in their ability to support in part due to issues arising from being swo
secrecy [30, 42].
This inability to communicate their emotions led some participants to engage in
in an attempt to release their feelings physically [21, 31, 33]. Indeed, the suicide a
may be interpreted as an attempt at communication, which was often an explicitly
objective [21, 36, 38, 47]. Self-harm was also reported to be a way of regaining co
aspect of the participant’s life [31, 36], to punish themselves for perceived deficien
to distract themselves from overwhelming negative emotions [41].
Many participants in these studies expressed a lack of future direction or focus a
associated with suicidal behaviour [25, 29, 35, 43] with those attempting suicide re
they did not know what their purpose in life was [29], that they had lost their futur
and that they lacked goals and plans [25]. Other behaviours commonly reported w
ing mood swings [34, 42] and engaging in high-risk activities [25], often involving
42].
Feelings/Emotions.The most frequently reported feelings associated with suicidali
were those of worthlessness [31, 41, 47], self-loathing [25] and other general self-e
[23, 43]. These issues sometimes stemmed from a dissatisfaction with one’s physi
ance [21, 22, 36] and are closely linked to the feelings of shame [21, 24]. These fe
usually associated with rejection, either real or imagined, by family members [21,
peers [25, 33].
Physical and emotional isolation was a major contributing factor in suicidal beha
Participants felt that those around them would not understand their experiences [2
46], that they were in some way different [25] or that no one cared [24]. Others fe
stigma associated with disclosing negative emotions [25]. The perception of isolati
in the person keeping their feelings a secret [34, 42, 45] and attempting suicide or
was an alternative to expressing emotions [21, 33].
Feelings of anger and aggression were also prevalent in many studies [21, 35, 4
cide attempt was a way of releasing the escalating anger within a young person [3
This anger, described as “uncontrollable” and “a loss of self-control” [35], rarely ha
ous cause. Anger was described as the one emotion that “became a safe way to sh
some of the negativity that dominated their lives” [25]. The anger for some partici
strong that their suicide attempt was intended as revenge designed to elicit guilt a
from those around them [36].
The intense emotional and physical experiences led young people to form a part
ion of death. To some, the negativity in their life resulted in death becoming an ap
cept as an “avenue to free them of the pain” [38], as “salvational” [36] and as “a c
In contrast, some reported a degree of ambivalence, not wanting necessarily to die
wanting to live [47], seeing no other alternative [34, 38] or simply being unable to
intent [33].
Family influences.Negative life experiences and triggering events, including the d
a family member or close friend [29, 34, 43, 46] played an important role in a youn
decision to end their life. Difficult relationships with family members was the most
reported issue in the lives of suicidal youth. Major family issues identified were rela
struggles with their mothers [21, 28, 29, 33, 34, 41, 46], distant or unavailable fath
34, 35, 46] and fractured families [23, 31, 35, 43]. Sibling conflicts also contributed
family life [21, 27, 29, 35, 41, 46]. Harsh criticism and strictness from family memb
34, 41] and difficulty with communication within the family [25, 32, 35] were key f
tributing to a problematic family dynamic. Some believed their suicide attempt wo
their relationships with their families [31], though this did not always the eventuat
Experiences and perceptions of youth suicide
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several studies, a history of family violence and childhood maltreatment was prese
47] contributing directly to suicidal ideation [31–35].
Peer influences.While difficulties at home were the most important contributor, m
studies also highlighted the importance of a young person’s social and school life.
demic challenges of schooling and the real or perceived underperformance at scho
in low self- esteem [28, 31, 32], parental disappointment [31, 32, 35, 44], stress [3
lying from peers [35]. In addition to the academic challenges, complex peer relatio
significant stressors. The importance of choosing the right friends [24, 27] who can
[46], difficulty connecting with peers [22, 25, 36] and bullying arising from social is
28, 31, 33, 43, 44] were also common peer influences contributing to suicidality.
Romantic relationships are important for young people, and solace in these relat
was especially important for those struggling with family and peer relationships. Th
these relationships or experiences of unrequited love were common sources of stre
suicidal ideation [23, 34–36, 43]. The failure of these relationships was sometimes
expectations [35]. The issue of teen pregnancy provides an emotional upheaval, in
when it results in the breakdown of the relationship [30, 41, 44].
There were significant challenges faced by members of minority cultures. Exper
prejudice [27, 31], the loss of one’s cultural identity [28, 30] and a longing to retur
country of one’s origin [31] were all identified as contributing to suicidal ideation. D
in cultural identity also existed between parents and their children leading to confl
ferences in generational expectations regarding culture [32, 34].
Other.Involvement in a deviant peer group could lead to experimentation with i
drugs and/or alcohol [21, 32]. Substance abuse, either by the young person [21, 24
42] or by a family member [23, 29, 30], was a common theme throughout the stud
many attempting suicide, drugs and alcohol were believed to be taken as a way to
or cope with intense emotions [23, 25, 27, 42]. Drug ingestion was a common met
harm and suicide [23, 30, 43], while addiction was highlighted by the community a
associated with suicide [39, 42].
Other experiences which influenced suicidality included previous experience wit
poor living conditions. Repeat suicide attempts were present [46], while many had
ber or friend who had committed suicide, prompting discussion about copycat beh
While the presence of suicide in a young person’s life is a risk factor and actual inc
copycat behaviour were reported [29, 30] there was a broader perception of suicid
46] which is likely to overstate this phenomenon. Unideal living conditions and exp
poverty were also discussed as an influence on youth suicide [30, 34, 35] with one
ing that she attempted suicide because she wished to “ease the financial burden o
Factors involved in recovery
Interpersonal.Following suicidal ideation, a number of factors were identified as h
in recovery. Most importantly, the development or improvement of interpersonal r
with family members [21, 24, 29, 33, 36, 38], peers [24] and mental health profess
be particularly helpful in moving past suicidality. Connection with at least one othe
33, 39, 43], including other patients in rehabilitation programs [47] was considered
tant for successful recovery. This development of new relationships is essential in
their self-esteem [21, 24, 25], which is another key theme in recovering from suicid
Changing or managing the physical and social environment in which a young pe
also assisted in the development of these stronger relationships and improved out
This may involve either relocating or changing schools [25]. Similarly, the developm
Experiences and perceptions of youth suicide
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stronger relationships with members of one’s family and community can help stren
person’s cultural and family value, [30, 39] and highlights the importance of a sup
ily in recovery [42]. For some, the attempt itself prompted families to provide more
than they previously had [24] and this change in home environment assisted recov
ing the therapeutic environment by allowing children to bring their own bed covers
and ensuring their room is physically comfortable (appropriate lighting and temper
considered supportive for children recovering from suicide attempts [40].
Cultural.Spirituality was another common theme throughout these studies. Som
that developing a stronger relationship with God [24] helped in their recovery, whi
felt that their religion discouraged suicidality [22, 34, 37, 43]. Spirituality was not,
always discussed as a way of recovering. Some felt that the tightness of their com
church group would stop them disclosing suicidal feelings [42] and one participant
their peer’s suicide was the result of a curse [44].
The importance of the wider community for recovery and prevention was a com
theme. It was felt that young people were excluded or let down by the unwillingne
community to adapt and include young people [26, 34]. In contrast, some Native A
communities invited Elders to engage with younger members of their tribe which w
in bridging the generational gap [28, 30].
Individual.Some common themes related to changes in the individual’s mindset
sonal factors which were considered important in recovery were the development
goals and direction, [25, 34, 43] and learning about life [39, 47] and feelings [43, 4
Need for institutional treatment/prevention strategies
Education.A number of common themes arose highlighting the need for educati
who should receive it. Many participants emphasised the need for improved and m
ble information concerning youth suicide [40, 44, 46]. The need for education in sc
regarding warning signs, access to help and risk factors were identified [23, 26, 42
the possibility of negative consequences from education initiatives, such as the no
or encouragement of copycat behaviour was a concern [45].
Treatment.There were also several themes which explore the best methods for t
and assistance with recovery. The ability to access the help of a health care profes
reoccurring theme [22–24, 38, 46, 47], although it was not always identified as bei
[30, 42]. Youth-specific initiatives were widely considered beneficial [28, 42, 44], a
cialised support for parents [26, 30, 40, 43]. Other themes identified as useful in tr
involved treating the persons’ situation holistically [40], including better and broad
ment [38, 42, 43], more realistic discharge expectations [30, 43] and an holistic ap
treatment of the mind and body [40].
Beliefs about suicide within the wider community
At the community level, many studies explored commonly held beliefs within socie
prevalent was the negative stigma associated with suicide [37, 39, 43]. Many attem
believed they would be judged poorly following an attempt [25, 29, 33, 39] or for e
negative thoughts and feelings [25, 26, 42]. A more subtle example of this stigma
the reoccurring ‘othering’ of suicide attempters by members of the community [26
process, people attribute a person’s suicidality to various demographic markers th
ent to their own, such as age [39], socio-economic status, gender [26] or race [23]
typing removes themselves from alignment with the issue. Much of this ‘othering’
a genuine desire to understand why suicide occurs, however misplaced [39].
Experiences and perceptions of youth suicide
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The association between suicide and mental illness was raised in many studies [
47], with issues relating to stigma highlighted. Media representations of youth suic
influenced people’s perceptions [26, 37, 42], which may overemphasise the incide
Discussion
The aim of this study was to review and synthesize qualitative studies that explore
ences and perceptions of suicide in people 25 years old and younger. By including
ences of suicidal young people alongside those of their friends and family, as well
discussions with health professionals and members of the wider community, we ho
commonalities and differences which explore the true complexity of the issue. Find
split into four broad themes which covered the risks and triggers for suicidal ideati
tant protective factors in moving past suicidal ideation, areas in which treatment/p
strategies could be improved and the beliefs held at a societal level. Due to the sc
review, these four categories remain broad in order to capture the variety within th
sub-categories and themes describe in more detail the specifics.
Relationships between themes
Whilst triggers were assigned into one of five sub-categories (behaviours, feelings/
family and peer influences and others), these terms are heterogenous and there is
of interconnectedness between them. The negative social influences in a person’s
lead them to exhibit behaviours or elicit feelings associated with suicidality. Simila
tive factors often involve the resolution of previously triggering experiences or beh
was also clear that some of the societal attitudes, such as the negative stigma of y
and self-harm, can also be contributing factors in youth suicide. Evidently. while th
gories have been reported separately, the inter-relationship between many of them
Participants frequently reported a lack of control over their lives [21, 31, 36], wh
resulted in self-harm or the desire to end their lives [31, 36]. The lack of control wa
related to the absence of future orientation and goal exhibited by many participan
35, 36, 43]. The perceived or real inability of control their own lives resulted in ma
affected young people not demonstrating an interest in their future as they perceiv
cannot influence the outcome or plan for future choices including success or failure
instance, this powerlessness was the result of parental restrictions which resulted
down of the young person’s significant relationship [35]. The traumatic experience
relationship was commonly the result of a difficult parental affiliation and caused t
tional experience of powerlessness in this important life event and hence future re
Peer relationships also demonstrated a complex interplay between young peopl
ences and emotions. Performing poorly at school impacted a child’s relationship w
parents [31, 32, 35, 44] as well as providing a source of antagonism from peers at
The resulting perception of failure can increase feelings of isolation which has a sig
negative impact on self-esteem for young people [31, 32]. The experience of being
often cited as a source of stress. While sometimes the result of poor academic per
cultural differences and prejudice were reported as important influences related to
[27, 31]. Negative associations with one’s culture as a result of this bullying can in
ings of isolation and lead to the degradation of cultural value, which provide impor
tive factors for mental health issues [30, 39].
The cultural challenges a child faces may also stem from intergenerational differ
Parents who have migrated to another country may have stronger or different cult
from those held by their children [32, 34]. Conflict can arise as the parent tries to e
Experiences and perceptions of youth suicide
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restrictions upon the child, resulting in resentment, animosity and, ultimately, a di
ent-child relationship. These cultural differences between caregivers and children e
beyond the experience of migration. Many of the young people in the included stu
experienced fractured family structures [23, 31, 35] with some raised largely by gr
[28, 43]. This generational difference and the shifting societal values over time can
tion at home and add to already complicated relationships. It is also important to c
that, while difficult family relationships were a common source of stress leading to
in these studies, the improvement of parent-child dynamics was also discussed as
the recovery after attempted suicide [24].
Relationships with empirical evidence
A number of the themes which emerged in this review are reflected in the current
empirical evidence that exists on suicide and associated risk factors. Family influen
family violence [1, 3, 4] or the death of a loved one [1, 3] have been shown to be l
suicidality, as have other social influences such as previous experience with suicid
ences of bullying [1] and social isolation [4]. Individual factors such as impulsivity [
lack of future direction [3], as well as a history of mental illness [4, 13], substance
self-harm [13] can also be predictive of suicidal behaviour and were all themes of t
Teaching school aged children skills in psychological assessment has had positive
reduction of suicidality [1], and the identification of the need for better education i
therefore, supported by empirical evidence.
Relationships with theoretical models
Many of the common themes found in this review also support the current theoreti
of suicide. One of the key components of the Interpersonal Theory of Suicide (IT) is
of ‘Thwarted Belongingness’ [4]. Themes such as isolation, difficult family and pee
ships and failure in love were common triggers/risks leading to suicidality and refle
nect in belonging and connectedness, which are key components in both the IT [4]
Step Theory (3ST) [6]. The 3ST, however, explains that connectedness can also pro
suicidality [6] and this does appear consistent with the findings of this review. The
improvement of relationships, a spiritual connection and community factors were i
as common themes in recovering from suicidality.
Another key component of the IT is ‘Perceived Burdensomeness’ [4]. While none
identified themes specifically reflected perceived burdensomeness, there were sev
of this reported in the included studies. One young person reported feeling that th
was suffering as a result of them [22], while a participant in another study suggest
her life would ease the financial burden on her family, who were living in poverty [
study, the father of a suicidal girl blamed her for having to cancel a trip to see exte
and costing him “thousands and thousands and thousands of dollars” [32]. While t
the perception of the suicidal young person, it is reasonable to assume that the bla
on her would result in the perception that she was a burden on her family. Though
ples were described by difficult family relationships and poor living condition them
clear examples of how perceived burdensomeness was present throughout this rev
The final element in the IT is that one must acquire the capability for suicide [4].
and previous experience with suicide are two ways that have been identified as pr
capability for suicide in the IT [4] and were commonly reported themes throughout
review. These themes are also Volitional Motivators in the Integrated Motivational-
Model which contribute in the transition from suicidal ideation to attempts [5]. The
Experiences and perceptions of youth suicide
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drugs and alcohol was also a common risk/trigger for suicidality in young people an
been shown to decrease sensitivity to pain. Hence, the capability for suicide, as ou
IT [4], could also be acquired through substance use as a tolerance for pain is heig
The use of drugs/alcohol was identified as a common theme in this review. Howe
this review includes such a wide range of participants, it is important to acknowled
delineation between the beliefs held by those in the community about suicide and
sions about actual instances of suicidal attempts. The use of drugs and alcohol wa
theme reported by those who attempted suicide [21, 25, 27, 41] including the dire
of substance use by their family members [23, 29, 30]. However, some of the stud
based around the beliefs of those within the wider community [39, 42]. In these ins
cussion about substance use was also prevalent, but usually this involved the ‘othe
cide attempters because of their association with drugs [39, 42] and the opinion th
abuse drugs are more likely to commit suicide.
Other themes in this review also support various aspects of the current theoretic
The 3ST explains how experiences of pain are important in developing suicidal idea
Experience with self-harm, family violence or poor living conditions may all be exa
physical pain experiences, while failure in love and difficult family and peer relation
themes which reflect the emotional pain which may lead to suicidality. Similarly, co
tion difficulties and a lack of future orientation reflect Threats to Self-Moderators a
tional Moderators, respectively, which are key elements of the IMV model which m
suicidality [5].
The death of a loved one and previous experience with suicide were common th
review. While these have been identified as ways of acquiring the capability for sui
Volitional Motivators in the IT [4] and IMV Model [5], respectively, they also relate t
of peer contagion [9] and the social transmission of suicidal ideation. Copycat beha
highlighted as a factor by some of the studies [29, 30], although the level of under
around the mechanisms through which this occurs was low. While the suggestion t
ing about suicidality can increase suicidal behaviour has been disproven [10], ther
ber of other explanations for the presence of these ‘cluster effects’. It is possible th
affecting one member of a social group will also affect their peers [1], or that suicid
is normalized within the group [12, 13]. When the young person has experienced t
of a family member, especially a parent, there may also be genetic influences or b
modelling consequences present [1]. The themes that have emerged in this review
to death are, therefore, expected.
Limitations
One limitation of this study was the broadness of scope. Including a significant num
studies has been useful in the ability of this review to address the range of topics o
and provides an excellent exploration of how young people’s experiences may diff
beliefs and experiences of others. The studies ranged greatly in scope and particip
ing interviews with attempters [24, 47], discussions with members of the commun
and interviews with health practitioners [43, 45]. The diversity of these studies allo
emergence of themes which are common to a variety of situations and demonstra
ceptions of triggers of youth suicide for those affected. However, the wide range o
inhibits the detailed exploration and reinforcement of sub-categories. The in-depth
of relationships between themes and emergence of reoccurring, smaller themes is
scope of this review and should be considered in future studies. Similarly, the sing
output used to report the findings of this review does not allow for the detailed exp
Experiences and perceptions of youth suicide
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cultural differences between the included studies and the impact that religion and
have on suicidality in young people.
Another aspect of this review worth noting is that, while common stressors and
have been identified through this review, they are not, in themselves, causes of su
While difficult relationships with family members have been identified as the most
negative experience of those who attempted suicide, they are also common exper
most young people which do generally not result in suicide attempt. It is important
that, while the triggers/risk factors identified in this review may be indicative of su
iour, they are not necessarily causes or even likely predictors. The experiences, bo
and physical, that contribute to youth suicide can be exacerbated by mental illnes
unique to the individual and their circumstances. Mental illness is also under-diagn
ticularly in young people, and hence this is not always identified before or even aft
attempt.
Implications for future research and practice
One of the reoccurring sub-categories in this review was the perceived need for be
tion about youth suicide, especially in schools [23, 26, 42, 44] to assist with detect
ing signs and reduce the social stigma surrounding the issue. However, there was
about the possibility that youth suicide education could encourage copycat behavi
other young people although this is not consistent with empirical research [10]. Di
Tipsord’s [9] study on peer contagion found that deviant behaviour appears to be
gious during unstructured portions of interventions. Hence, it may be proposed tha
tive consequences of peer contagion may be minimized by structured intervention
supervision [9] and future research should explore the degree to which these prog
tangible benefits, rather than just filling a perceived need, and best practice in suc
The prevalence and consequences of the social stigma associated with suicidal i
emotional expression was a common theme of this review. As a result, it is clear th
need to reduce the stigma surrounding negative emotions and suicide ideation. Fe
lation result from an inability to communicate with others about feelings, often bec
young person fears judgement [25, 26, 42] or believes they are alone in these feel
38, 46]. Isolation can lead some young people to engage in self-harm and suicidal
an attempt to cope with or escape from the overwhelming emotions they feel they
share with others without being persecuted [21, 33]. This demonstrates a clear ne
age communication and break down negative stigma within the wider community.
research should explore the various aspects of this social stigma with an aim of ide
methods of reducing it and the effectiveness of program designs assessed through
research.
Another key theme of this review centred around the current treatment procedu
ing a suicide attempt and the perceived need for their improvement. Inadequate tr
and assessment of, young people experiencing suicidal ideation provide little or no
ment of the person often resulting in further suicide attempts. It is, therefore, impo
these treatment and assessment practices are enhanced to be more effective and
dences of youth suicide. This review highlights a number of ways that young peopl
tioners perceive this could be achieved. Treating the individual as a whole person
considering their mental health, as well as their physical health, upon presentation
attempt was a widely reported area for improvement [40, 43]. Similarly, managing
expectations [43] and both treating and educating parents was also identified [26,
Experiences and perceptions of youth suicide
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Future research should explore the efficacy and need for these improvements to in
practice in patient care post suicide attempt.
Conclusion
The use of qualitative studies provides important insight into the lived experience
ideation in young people, and the experiences of their parents and practitioners. A
standing of the interplay of motivators of young people towards suicide requires th
and synthesis of qualitative data which is similarly complex allowing for the full ex
the various contributing factors. The diversity of the studies in this review allowed
tification of the richness of factors in a young person’s life which contribute to suic
tion. Themes relating to a person’s recovery following an attempt, institutional trea
prevention strategies and the beliefs held about suicide at the community level we
tified. The overlap between themes within and between these categories highlight
nature of youth suicide which can inform future primary research studies, policy an
practice.
Supporting information
S1 Table. ENTREQ.
(DOCX)
S2 Table. Sample search strategy.
(DOCX)
Acknowledgments
We would like to acknowledge the support provided by the School of Health Scienc
of Health and Medicine, University of Tasmania through the 2018 Summer Student
Scholarship.
Author Contributions
Conceptualization: Rachel Kornhaber, Michelle Cleary.
Data curation: Jessica Grimmond, Rachel Kornhaber, Denis Visentin, Michelle Cle
Formal analysis: Jessica Grimmond, Rachel Kornhaber, Denis Visentin, Michelle C
Investigation: Jessica Grimmond, Rachel Kornhaber, Denis Visentin, Michelle Clea
Methodology: Jessica Grimmond, Rachel Kornhaber, Denis Visentin, Michelle Clea
Project administration: Jessica Grimmond, Michelle Cleary.
Resources: Michelle Cleary.
Supervision: Rachel Kornhaber, Denis Visentin, Michelle Cleary.
Validation: Jessica Grimmond, Rachel Kornhaber, Denis Visentin, Michelle Cleary.
Visualization: Jessica Grimmond, Rachel Kornhaber, Denis Visentin, Michelle Clea
Writing – original draft: Jessica Grimmond, Rachel Kornhaber, Denis Visentin, M
Cleary.
Writing – review & editing: Jessica Grimmond, Rachel Kornhaber, Denis Visentin
Cleary.
Experiences and perceptions of youth suicide
PLOS ONE | https://doi.org/10.1371/journal.pone.0217568 June 12, 2019 22 / 25

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