What can we do to better understand and prevent suicide among young people? In part one of our two-part series, Christine Yu Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention, explores what science tells us about youth suicide risk, including the protective power of belonging, the impact of loneliness and social media, emerging concerns around AI chatbots, and how adults can start a potentially lifesaving conversation.
Featuring:
Christine Yu Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention
Host/Producer: Carol Vassar
TRANSCRIPT
Announcer (00:00):
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Carol Vassar, podcast host/co-producer (00:12):
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Well Beyond Medicine.
Carol Vassar, podcast host/co-producer (00:36):
Many years ago when my older daughter was in middle school, a 13-year-old classmate died by suicide. Now, that news left the students, the families, actually our entire community, really struggling to understand how a young person described in newspaper articles of the time as being bright and outgoing and well-liked could be gone. For more than a few of us, youth suicide has a face and a family and a circle of young people who are forever changed by the loss. September is suicide prevention month, and it’s the time to consider how we can address and prevent death by suicide, especially amongst our youth. In this first of two episodes on youth mental health and suicide prevention, we’re going to explore what science tells us about suicide risk, the protective power of belonging, the influences of loneliness, social media, and emerging technologies, and we’re going to learn more about the prevalence of suicide in the nation today, really focusing on our youth.
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We’re going to be talking about suicide and suicide prevention in depth on these episodes. And I want to remind everyone who’s listening, everyone who’s watching, that if you or someone you know is experiencing a mental health crisis or thoughts of harm to yourself or to others, the Suicide and Crisis Lifeline is available 24/7 across the nation. All you have to do is call 988 or text the word help to 988.
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Joining me right now is Dr. Christine Moultier. She’s a psychiatrist and chief medical officer of the American Foundation for Suicide Prevention. She has also been personally affected by several suicides that occurred during her medical training and early in her career, which really has led her to commit to understanding suicide risk and what individuals, families, healthcare providers, schools, and communities can do to save lives. Dr. Moultier has asked me to call her Christine. So Christine, welcome to the Well Beyond Medicine Podcast.
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (02:45):
Thank you so much for having me, Carol, and thank you for focusing on this important issue.
Carol Vassar, podcast host/co-producer (02:50):
I’d like to start with the national landscape. What is the latest evidence, and what does it tell us about suicide among adolescents and young adults?
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (03:01):
Sure. So suicide is unfortunately the second-leading cause of death among youth and young adults from really 10 to 34 years old in the United States. Some other kind of grounding data to know are that suicide rates are much, much lower among young children, but begin to rise during adolescence and kind of post-puberty. The latest data from the CDC, which was finalized data was in 2024, actually shows that there was a 4% decrease year over year for youth and young adults, and that was a bit of a glimmer of hope because there have been generally upgoing trends over the longer period of time, like if you look at the last decade. And sadly, when you look back starting around 2013 through the present time, not only the suicide rates, but when you look at the CDC’s Youth Risk Behavior Survey, which measures high schoolers, by self-report, all sorts of what are considered risky behaviors from smoking to other behaviors and includes things about mental health experiences and suicidal thoughts and behavior, and all of those measures related to mental health, suicidal thoughts and behaviors have gotten worse over the last decade or decade and a half.
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So that at the present time, the best data we have shows that two in 10 high school students had seriously considered attempting suicide and nearly one in 10 reported attempting suicide, and this is measured over the last 30 days, is the way that they’re asked. So that is far, far too common. And it’s also the case that when a young person dies by suicide, there’s a high likelihood that they have seen a doctor or a healthcare provider in the weeks to months prior to their death, but up until several years ago, we were not paying attention to suicide risk as a general health or safety goal among pediatricians’ offices and educating parents and so forth. So it is the case now that at age 12 and up, pediatricians are encouraged to universally screen for suicide risk so that we can actually detect this kind of distress because many kids who are in distress and having suicidal thoughts are not necessarily talking to anyone, peers or trusted adults in their life, and if they do speak out about it, they’re more likely to turn to a peer. So that’s some of the latest data.
Carol Vassar, podcast host/co-producer (06:03):
You started on a note of hope, and then everything else was concerning. Let’s talk about some of the risk factors. Anxiety is going up, depression is going up, loneliness is an epidemic according to one former Surgeon General. Is there a corresponding connection with suicide risk with all of those risk factors?
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (06:31):
Oh, absolutely. There’s quite a bit of research on which are the risk factors that bear themselves out to increase the likelihood of suicide among youth and young adults, and the key thing to know about these research-informed risk factors that include many mental health factors, but not just mental health conditions, but issues like what they’re experiencing in their home environment or at school, those environmental features are incredibly important. With regard to any risk factor, whether we’re talking about depression or substance use or early childhood adversity, it’s not one risk factor really ever on its own that shows up as causal on its own. It’s always the culmination and a convergence of multiple risk factors. And certainly the fact that there have been these sort of secular or societal trends going on, whether it’s related to social media or academic pressures or family structure or just the changing kind of overall societal environment.
(07:42):
And some demographic groups are affected differently, of course, by all of those things. If you think about race, ethnicity, where you live in the country, geography, as well as sexual orientation, gender identity, LGBTQ kids and young adults certainly experience more discrimination, more violence, all of those. But again, remember it’s not one of them on its own, it’s the layering effect, it’s the pile-up like straws on a camel’s back. And so the fact that there are these trends that show that suffering, loneliness, feeling sad or hopeless- those experiences are generally getting worse among young people- that we think absolutely has very much to do with suicide rates. And then you need to add in other things like access to physical and mental health care and access to lethal means, especially lethal means in the home environment. If I were going to sum up, those are some of the top risk factors, but not even comprehensively. There are others as well.
Carol Vassar, podcast host/co-producer (08:52):
What I’m hearing as you put layer upon layer upon layer of risk factor, if there’s a lethal means in the home, I’m assuming you’re meaning mainly firearms, that there is no one solution to youth suicide issues.
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (09:10):
That’s right. We have to look at the top-line risk factors for any given population of youth and young adults, and then really strategically and systematically and through research-informed methods, go… Suicide prevention work is always going to be a multi-pronged type of approach where you’re thinking about the public health model that kind of attacks the universal layer with education so that everyone in a population knows certain A, B, Cs. If you think about heart disease, most citizens and even kids and certainly young adults know something about preventing death by heart disease or other common causes of death in our nation. Don’t smoke, manage your stress, question mark red wine, exercise, healthy relationships, manage your blood pressure, your cholesterol. Most adults know that. So the public health layer of suicide prevention, which we’re hard at work on at AFSP, is trying to elevate the public’s understanding of suicide risk and prevention, and what anyone can do.
(10:29):
We all play a role in not only our own mental health, we play a role with each other because interpersonal connectedness is such a strong and protective factor, and it’s one that probably has degraded the most actually in modern-day living. So yes, I want everyone to understand this public health lens on suicide that has the universal layer of the approach. And then there’s the next layer up for any public health outcome is going to look at who are the groups of people who have elevated risk, and then there are specific strategies to employ to try to support them and reduce their risk. And then some of the kinds of top layers of a public health approach include clinical treatment and crisis services. And I also want to point out that in the suicide prevention movement, people who are suicide loss survivors, as well as people with our own lived experience… Which lived experience can include loss, your own suicidal struggle, surviving a suicide attempt, or supporting someone you love or in your life through any of those kinds of struggles; those are all forms of lived experience.
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And the suicide prevention movement is fueled by, really, it’s not an exaggeration now to say, as AFSP has been at this for some decades, millions of Americans who come out and walk for the cause in the Out of the Darkness Walk. It not only raises funds for the research and advocacy and everything, but it raises awareness, and it normalizes being able to talk about struggle. We never want to normalize suicide as a way of coping with pain or hopelessness, but we want to normalize everything that leads up to that and certainly the help-seeking and the leaning on each other for support because those are things that can absolutely make a big difference and reduce suicide risk.
Carol Vassar, podcast host/co-producer (12:33):
Clearly a public health approach is what is required here. You mentioned some of the populations of young people at greater risk for suicide. What does the research tell us about them, and how can that knowledge help us shape more targeted prevention efforts in the public health realm and in other ways?
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (12:55):
Yes. So in the United States, across different demographic groupings of youth and young adults, there’s a few things that stand out. In 2023, for example, LGBTQ and American Indian Alaska natives and female high school students were in the highest level groups of experiencing persistent feelings of sadness, hopelessness, having poor measures of mental health, reporting suicidal thoughts or behaviors. So, for example, more than three in five LGBTQ students did express persistent feelings of sadness or hopelessness. More than three in five. And one in five attempted suicide in the year prior. And we never think of these elevated risks as being something that’s sort of inherent to that identity of either LGBTQ, American Indian, or being female. It’s about the experience in society, in the settings we live in, that converges and produces that increase in those distress experiences.
(14:07):
There’s another group that I want to highlight, and that is young people experiencing neurodivergent brain functioning and differences, and sometimes it’s this discrepancy for some of them between high, high capabilities but problems functioning, and that discrepancy or the masking, the camouflaging that many just inherently learn to do is exhausting, let alone the sort of discrimination and bullying that can happen. And it’s even the case among this neurodivergent sort of umbrella that students with ADHD attempt suicide at a rate nearly two and a half times higher than students without ADHD. And I think many, even clinicians, have tended to think of ADHD as not a terribly serious or severe mental illness or psychiatric condition, but in fact, it creates all kinds of issues in terms of that discrepancy with functioning and the impact on self-esteem and the effort that goes into that and the challenges to sort of stabilize that. It has actually also been shown that treatment with medication for ADHD has been shown to reduce suicidal behavior. That’s also probably a very little-known research finding because there’s so many opinions about psychiatric medications, and some of them are not well-founded, actually.
Carol Vassar, podcast host/co-producer (15:40):
It sounds like being connected, not being considered other, being included can help to reduce a young person’s suicide risk. Is that a fair statement?
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (15:53):
Absolutely. I mentioned already interpersonal connectedness, but it’s also… A kid from the outside can look like… Like you mentioned, you’re the child that had died in your family’s life or school, that from the outside it can look like, and they can be very popular, very well-liked, but their internal experience waxing and waning over time, maybe not in a permanent way, can feel isolated, disconnected, and then let alone if they’re living with something like autism or ADHD, or are in a queer or questioning or figuring that out and reading all the cues that they’re receiving in their peer group at school and in the home environment and out in the community and all of those. Sense of belonging, sense of purpose, those are incredibly strong protective factors. And also think about the developmental stage that youth and young adults are going through. There are several psychological milestones that really are about transition.
(17:09):
They are needing to… By nature of achieving young adulthood status from a psychological milestone standpoint, they have to actually separate and individuate from their family of origin, which produces friction within the family. Sometimes, if parents don’t understand that this is a healthy milestone that their pre-teen or teenager is going through, of course you need safety and boundaries, and you can set healthy expectations to allow them some space, but also to have some way to have some limits. We used to think of you can do your own thing, you need to be your own person, and some of that is going to be definitely pushing back against us as the parents, but where the limit would be with are things that are unsafe, of course, or when the behavior is so disrespectful that we need to actually give them that feedback because to not do so would actually be a disservice to their sense of being really actually connected in the family as well as sort of how we treat people.
(18:25):
So I mean, these are very, very challenging issues I think for youth and young adults. They’re not scholars in development or mental health or loneliness, belongingness, all these things. They’re going through their life experiencing this. And as parents, I think one of the things, again, according to the public health model, is if parents can get a little more educated about some of these basic tenets of development and parenting and behaviors in the home that can support youth and young adults’ development, even though it’s very messy; there are unpredictable things that happen. Believe me, I’ve lived that myself, but that is part of the public health strategy is to educate both students directly, but also parents, also teachers, anyone who is involved in youth and young adults’ lives like coaches and youth pastors or Boys and Girls Club staff, YMCA – all of that is part of the public health approach to suicide prevention.
Carol Vassar, podcast host/co-producer (19:29):
As we look at that public health approach, what’s been added on in the time since what happened when my daughter was young is the social media factor. How do social media platforms influence youth mental health and suicide risk? And again, are some young people more vulnerable based on the effects of social media algorithms, for example?
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (19:55):
Absolutely. You said it correctly. And the tricky thing about something like social media – perhaps we will talk about AI chatbots and those platforms because their level of utilization is also rising up as to be so commonplace, like social media and screen time, has become that we have to think about it both as an overall population effect in terms of… If something, for example, has the potential to influence the development of neural networks, and we think about even very young children, two, three, four years old, who are on screens, who are actually thinking about AI chatbots, there are toys that are made for infants and toddlers that have AI chatbots built into the plush teddy bear or whatnot.
(20:52):
And so I think parents need to use a lot of caution because even if your child doesn’t have, let’s say, family history for mental illness or suicidal behavior or genetic loading or early childhood adversity that might lead to additional risks and vulnerabilities like the ACEs study shows, that there can be this sort of population level effect that the exposure, and especially heavy use, numerous hours on screens. But what you said is also true that kids, especially girls in some studies, have a higher predisposition for, for example, body dissatisfaction. And look, living in our society is very, very challenging, and I think body positivity is a really important, strong force to counter this illusion of what girls should be aiming for. But things like baseline anxiety, a tendency towards body image distortion of their own expectations and their view of themselves, or an overload of sense of value based on these kinds of physical or external image aspects.
(22:15):
All of that, if there are any preexisting kind of ways that a kid is already showing up in terms of anxiety, depression, eating disorders, body image, comparison and a fear of missing out, all those things that it’s going to bother anyone if they’re exposed to enough negative imagery and messages on social media, but for those who have these vulnerabilities, it can be exponentially worse. And then remember, social media is interactive. And so also what can happen is that those vulnerabilities then play out with them looking for affirmation or responsiveness from others in that social media world, which for them is like in real life. And that interplay can spiral downward when they are already lacking that sense of groundedness in who they are. And look, which teenagers have that sense of groundedness anyway? But you know what I mean, it can be different for different kids. So those baseline factors are very much also important to think about knowing your child, and there may be additional sort of monitoring and guidance and support and restricted time or types of exposure that I know this is very hard to accomplish, but that parents can strive for.
Carol Vassar, podcast host/co-producer (23:50):
Let’s talk about those AI chatbots. I had never heard that there are AI chat types of toys for two-, three-, and four-year-olds. I want to ask first, does that in some way rewire the brain in ways that are going to be detrimental to the child to their mental health, and maybe I’m taking this a step too far, putting them at risk for suicide?
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (24:14):
We don’t know that yet, but there is early research about these effects, again, of heavy long hours of exposure to AI bots, especially if, remember, it’s sort of a zero-sum game in terms of time in infancy and those toddler years that what is required for healthy development is a strong dyadic parental maternal or paternal infant bonding, and that does not happen with an AI chatbot. And I think, as a general rule with AI chatbots, I would say the starting place is to be vigilant, to watch for ourselves, our own mindset, that we’re constantly reminding ourselves that no matter how human or surprisingly intelligent or personalized the communication feels, these LLMs are using predictive modeling, basically mathematics, to feed back the dialogue. There is no human, there is no soul or spirit or human being on the other end of that, but it’s very tricky because the experience can feel so helpful to some.
(25:42):
So anyway, some of the early research is quite concerning actually about not just changes to neural development, but again, that absence of the natural and healthy family dynamics that can go on. And we just need to be very careful to not be setting up our infants and children in lieu of our attention with these bots and toys and screen time.
Carol Vassar, podcast host/co-producer (26:12):
It’s not a real human-to-human bond. It’s a human to an LLM.
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (26:17):
Yeah, that’s right. Yeah.
Carol Vassar, podcast host/co-producer (26:19):
So do you think as kids get older and they are on the internet and they do find AI chatbots, they look for companionship, emotional support, and help during moments of distress, is there a legitimate potential for use by teens to help them? And are there also risks, which I think you’ve already delineated, and guardrails that you think require some urgent attention, attention right now?
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (26:50):
Yeah, I think, like, anything, it’s a tool. It can be used in a lot of different ways for good, can have harmful effects, and everything in between; it can be a mixture. And kind of like we saw with social media, for kids who are not finding or were not finding social connection or affirmation, acceptance for their true identity, whatever that might be, including LGBTQ, but other forms of identity and intersecting identities, social media does provide… In many cases, they find community and connection and affirmation in a way that safe haven. But of course, the problem is that they need to be finding that out there in the “real world” and in their home environment and with real-life peers and teachers as well.
(27:44):
So with AI, there is the potential to lead people to help, and certainly when suicide risk is detected, there are already programs and things in place. Although the problem with AI is that it’s not actually programmed, per se. It doesn’t stick to a program. It’s doing its own independent predictive modeling analysis as time goes on. And so the longer the chat goes on, the more it tends to kind of derail off of those safety guardrails to offer 988, for example, to discourage suicidal behavior, to encourage the young person to talk to someone they trust about what they’re going through.
(28:30):
Sometimes we see in these tragic instances of suicides where there had been lengthy dialogues with an AI chatbot or on platforms also, like Character.AI, not just the large LLMs like ChatGPT or Claude, but that these lengthy, lengthy dialogues can derail and devolve into the AI actually, believe it or not, encouraging suicide, giving specific instructions on lethal means. There’s also some cases where psychosis or delusions are sort of reinforced, and the person essentially becomes more and more ill and psychotic through the interaction. So it can be a powerful force that we need to be aware of.
Carol Vassar, podcast host/co-producer (29:22):
I want to finish up today by asking what I think is a really important question, and that is when a parent or an educator or a friend or another trusted adult is worried about a young person, what is the best way to begin the conversation? There are some who say there’s a danger in asking directly about suicide or suicidal ideation. Should we be asking that of our young people, and what should happen if the answer turns out to be yes?
Christine Moultier, MD, Chief Medical Officer, American Foundation for Suicide Prevention (29:50):
Okay, right. So most likely you’re tuning into this part of the conversation, hopefully generally at all times in our lives, but if you’re worried about someone, there is a reason your gut instinct is having you worry about someone. And I think we use all kinds of reasons that we’re socialized to do in our society to avoid moving in and towards the person. This doesn’t even have to be a loved one. It can be a friend, a coworker, an acquaintance. And so don’t assume that you are not the right person to have this caring conversation. I always start by inviting psychological safety by saying, “I want to have this conversation because I care about you. I sense that you might be going through some hard challenges right now, and I really want to support you, and in order to support you, it’s really just my goal is to learn more about what is happening for you in your life.”
(30:54):
So it’s really open-ended. That’s the starting place, whatever that… Put it in your own words, but it’s expressing care, no judgment, and kind of a supportive curiosity that is inviting them to go deeper than just, “I’m fine,” or, “I’m going through a tough spot with my grades at school. It’s okay, it’s going to be fine.” We’re so socialized to keep it very superficial, but it’s not that hard. If someone were to tell you about anything else that’s private or of concern, you would feel like, “Oh my gosh, they trust me, and I need to handle this with care.” And so it is not dangerous to ask about suicidal thoughts. In fact, that’s the opposite.
(31:43):
If you don’t ask, they may be keeping it inside, and then it’s left to spiral and stew and not get the help they need. Whereas when you ask, and the way that I ask it is in that open-ended start of a conversation, hopefully they will engage. If not, it’s okay. Don’t force it necessarily. You can always come back to them later on. Don’t give up, don’t take it personally. They may be afraid, most likely, of what will happen if they share the truth of the hard stuff they’re going through. So what I do is I say, “When you talk about…” And I use their own words, whatever they just said. When you talk about feeling so overwhelmed that you just, whatever it is, that you want to give up, or the relationship that you’re describing sounds so difficult right now, it does make me wonder if you’re having thoughts about ending your life.
(32:47):
And I ask it like that, or it’s more of a statement, and just be quiet after you put that out there and let them respond to it. If they say, “Yes, I actually have. I’ve thought maybe it’d be better if I didn’t wake up,” that is a form of a passive suicide wish, and you can ask things like, “Oh my God…” I would treat it… Again, they’ve just told you they’re in some pain. Say, “Oh my goodness, I’m so sorry you are suffering like that. I’m grateful that you trusted me to tell me that, and if it’s okay, I’d like to understand more about how that works for you. How long have you been feeling that way?” They’re just basic questions that you would ask anybody. If they told you, “I’m having a migraine,” you’d say, “Oh my goodness, I’m sorry. Has it been going all day? What makes it better? What makes it worse?”
(33:43):
You’re not turning yourself into a therapist or a mental health clinician. You’re being a friend or a parent or a coworker. You’re being caring like you would if they told you about anything else that was distressing them in their life. Hopefully we have that ability to do that. And if you’re not sure… It would be a rare moment. Even if someone is having suicidal thoughts, it would be extremely rare that they are immediately about to act on those thoughts because we talked about the data earlier. In any 30-day period, it’s about one in 10 to two in 10 kids are having suicidal thoughts or even have made an attempt. So if we intercept them while they’re experiencing this kind of distress, it is not likely that it’s imminent. If you are not sure, though, you can ask, “Do you have a plan? Do you have a way to carry out that plan?” You can ask those kinds of things, but you also need to know you don’t have to do any of that.
(34:42):
If you’re not sure, you can call 988 as the helping person. You don’t have to be the person in distress, and they will help guide you through what to do next. But I do want to say that not everyone who’s having a suicidal thought needs to go to the ER. It’s only when there is no other option to get linked up with help and when safety is of imminent concern. I would not call 911 if they’re not imminently about to act or in the process of attempting. 988, however, is our mental health resource and crisis and suicide lifeline, available 24/7 for all of us for guidance and help. Very different from 911.
Carol Vassar, podcast host/co-producer (35:30):
Dr. Christine Moultier is a psychiatrist and the Chief Medical Officer for the American Foundation for Suicide Prevention.
Carol Vassar, podcast host/co-producer
Thanks to Christine for sharing her time and expertise. Remember, 9-8-8 is the Suicide and Crisis Lifeline, available by phone or text across the nation 24/7, every day of the year, and, as Christine pointed out, 9-8-8 is available for those dealing with a mental health crisis and for those who may know someone who is. To clarify, though, if the person is in imminent danger – actively harming themselves or threatening or physically harming others – please call 9-1-1.
As I mentioned earlier, this is a two-part episode as we honor September as National Suicide Prevention Month and dig into today’s crisis of youth mental health and suicide prevention. Part two moves from understanding individual suicide risk to examining the data and public policies that can help prevent youth suicide at a population level, and we’ll take a look at that with help from experts at Trust for America’s Health, the Bursky School of Public Health at Washington University in St. Louis, and Nemours. Don’t miss it.
In fact, don’t miss an episode of the Nemours Well Beyond Medicine podcast from now on. Subscribe to it on your favorite podcast app, or by visiting our website, nemourswellbeyond.org. Go there and let us know how we’re doing, what you’d like to hear on future episodes, and to subscribe to our monthly e-newsletter. That’s nemourswellbeyond.org. You can also find the podcast on the Nemours YouTube page.
Our production team for this episode includes Lauren Teta, Cheryl Munn, Susan Massucci, and Alex Wall, Video production by SarahKate Reger, Audio production by me. I’m Carol Vassar. Thanks for listening, and remember that together, we can change children’s health for good – well beyond medicine.
MUSIC (36:12):
Let’s go – well beyond medicine
