The relationship between suicidal behavior and productive activities of young adults.

• Author: Tekin, Erdal

1. Introduction

   Suicides among youths have reached an alarming rate in recent years and are now the third leading cause of death for those aged 15-24 years (Anderson and Smith 2003). Since 1950, the suicide rate has tripled among youths (Cutler, Glaeser, and Norberg 2001). Even more striking is the number of suicide attempts by young individuals. For every teen who commits suicide, as many as 150 teens attempt suicide (Chatterji et al. 2004). Concern over the health and well-being of youths has prompted the U.S. Department of Health and Human Services to develop a national strategy for suicide prevention. This comprehensive campaign includes developing public education campaigns; increasing the number of suicide prevention programs in schools, work sites, and community services; and incorporating screening at primary health care facilities.

   Suicide attempts, regardless of whether or not they are completed, impose real health care and other costs on individuals and society. For example, the direct medical costs associated with both completed and medically treated suicides by youths under the age of 21 years amounted to $945 million in 1996, and lost future earnings are estimated at $2.85 billion (Miller, Covington, and Jensen 1999). A suicide attempt can have adverse effects on one's current and future labor market productivity as a result of a bodily injury or permanent disability, lost credibility in the workplace, interruptions at work and school, lost interest in future employment efforts, and continuing psychological problems. Despite this strong link between suicidal behavior and labor market outcomes, our knowledge of the potential effects of suicidal behavior on labor market and school outcomes is very limited. This relationship is also confounded by the potential effects that poor school or labor market outcomes have in contributing to suicidal behaviors.

   This paper explores in depth the link between suicidal behaviors and engaging in productive activities. Specifically, we focus on labor market and educational outcomes of young adults who are at a stage in life characterized by intense investment in human capital. These adults are in school, participating in job training, or are just starting their careers. Disruptions to these investments can have profound, long-term implications for future earnings and occupational choices. If there is a positive link between the quality of the initial job and future labor market success, the answer to this question will provide important insights into the long-term effects of suicidal behavior. In addition, it will help structure a better-informed policy debate over the effectiveness of cognitive behavioral therapies and anti-suicide programs such as those implemented at high schools in the United States.

   A study by the Centers for Disease Control and Prevention (1992) documents that most anti-suicide programs focus on teenagers, with little emphasis given to suicide among young adults. This is partly due to the fact that teenagers in high school are easier to reach than young adults and partly due to a failure to appreciate that the suicide rate is generally twice as high among persons 20-24 years of age as it is among adolescents 15-19 years of age. The study recommends an expansion of the suicide prevention efforts for young adults 20-24 years of age.

2. Background

   Researchers believe that almost all individuals who commit suicide have a diagnosable mental disorder, and mental illnesses are also primary risk factors for suicide thoughts and attempts (Johnson, Weissman, and Klerman 1990; Maris et al. 1992; Alexopoulos et al. 1999). It has been estimated that two-thirds of people who commit suicide have a depressive illness; 5% suffer from schizophrenia; and 10% meet the criteria for other mental illnesses, including borderline personality disorder. The relationship between mental illness and suicidal behaviors also holds for youth (Fergusson and Woodward 2002). One estimate shows that over 90% of children and adolescents who commit suicide have a mental disorder (Shaffer and Craft 1999).

   While depressive illnesses are most commonly associated with suicidal behaviors, other disorders are also frequently observed, including substance abuse disorders, attention deficit disorder, anxiety disorders, panic disorder, schizophrenic disorders, post-traumatic stress disorders, and borderline personality disorders (Johnson, Weissman, and Klerman 1990; Alexopoulos et al. 1999; Goldsmith et al. 2002). For example, in a study of youth in a psychiatric hospital, Borst and Noam (1989) find that conduct disorders are the most prevalent type of disorders diagnosed among suicide attempters. The authors conclude that "factors such as impulsivity and anger may contribute significantly to suicidal behavior in children and adolescents" (p. 174). Personality disorders are also highly prevalent, with a diagnosis rate of 40-53% among youth who have committed suicide (Goldsmith et al. 2002).

   It is important to note that the mental illnesses that manifest themselves through suicidal behaviors likely represent the most severe cases of illness. Simon and Von Korff (1998) find that among insured patients receiving treatment for depression, the highest risk of suicide was among those receiving inpatient treatment and medication, and the lowest risk was found among individuals receiving outpatient treatment without medication.

   Cutler, Glaeser, and Norberg (2001) argue that there is a fundamental difference between suicide attempts and completions among youth, where the latter is a result of the desire to die and the former is not. The authors discuss four reasons for suicide attempts among youth: The first involves strategic motives to "... signal others that they are unhappy or to punish others for their unhappiness" (p. 233). The second is the depression theory, in which youths cross some unhappiness threshold and desire to take their own lives. The third is the contagion theory, in which a '"social multiplier' may amplify the effects of stressors leading to depression or may amplify the effects of factors leading to suicidal signaling as a method of conflict resolution among youths" (pp. 233-4). The fourth theory involves the combination of unhappiness and the means to kill themselves. Even in the absence of the intent to die, it is clear that underlying mental states are extremely important in the theories predicting suicidal behaviors.

   In contrast to the conclusions drawn by Cutler, Glaeser, and Norberg (2001), Boergers, Spirito, and Donaldson (1998) find that most adolescents who attempt suicide cite the desire to die or the desire to obtain relief from a terrible state of mind as the primary reasons for the attempt. Few identify the attempt as a cry for help or as a way of "getting back" at someone. Although it is difficult to pinpoint the exact underlying motives for a suicide thought or attempt, the link between suicide and mental illness cannot be denied.

   In this paper, we focus on suicidal behaviors such as suicidal thoughts and attempts rather than depression or any other specific mental illness. Based on the literature described above, we argue that suicide ideation and attempts are most likely manifestations of severe mental illnesses. However, we also allow for the possibility that, in youth, these behaviors may be methods of signaling or punishing others or of conflict resolution. We believe that given the vast number of different mental illnesses and related stressors that are believed to contribute to suicide behaviors, estimating models of one or two specific illnesses is unlikely to draw a complete and informative picture of the effects of mental well-being on productive activities.

   Regardless of the underlying causes, suicide thoughts and attempts may have negative consequences for school and labor market outcomes through multiple channels and are therefore important to study. For example, injuries from failed suicide attempts may contribute to absenteeism and reduced productivity at work and school. About 116,000 individuals who survive a suicide attempt are hospitalized, with an average hospital stay of 10 days and an average cost of $15,000 (Miller 1995). Seventeen percent of these people are permanently disabled and are therefore restricted in their ability to work (Miller 1995). Suicidal behavior may also result in lower engagement in work and schooling activities as a result of reduced concentration and cognitive abilities (Greenberg et al. 1990; Conti and Burton 1994). These functional limitations may also contribute to worsened labor market and school outcomes. Furthermore, the underlying mental illnesses and life stressors that we observe through suicidal behaviors may also contribute to outcomes such as teenage pregnancy and marital instability, which may then result in low educational attainment, poor labor market productivity, and lower wages (Kessler et al. 1997; Overbeek et al. 2003).

   There is evidence that individuals with mental illnesses and those who exhibit suicidal behaviors are less likely to reach their potential academically. According to the Department of Education, 50% of children with serious emotional and behavioral problems drop out of high school, compared to 30% of students with other disabilities (U.S. Department of Education 2001). Stoep et al. (2003) find that over half of the adolescents in the United States who fail to complete their secondary education have a diagnosable psychiatric disorder. Using a twin sample from Minnesota, Marmorstein and Iacono (2001) conclude that depression is related to significant difficulties in functioning and school adjustment, which result in an increased number of suspensions and failure of classes. Slap, Goodman, and Huang (2001) document that those who attempt suicide perform more poorly at school and have a lower level of school connectedness than do non-attempters.

   In sum, suicidal...