# Suicide Risk and Protective Factors Among Medicaid-Enrolled Black Youth With a Mental Health Diagnosis

## TL;DR

This study identifies individual, family, and community factors linked to higher suicide risk among Black youth with mental health diagnoses who are enrolled in Medicaid.

## Contribution

The study provides a comprehensive analysis of multilevel factors influencing suicide risk in a specific and understudied population of Black youth.

## Key findings

- Suicide risk was higher for youth with depression, psychosis, prior suicide attempts, and those in foster care or with disabilities.
- Living in urban areas or high social vulnerability regions increased risk, while areas with more religious institutions showed reduced risk.
- Prior deliberate self-harm had the highest population attributable risk for suicide in this group.

## Abstract

What factors are associated with suicide among Medicaid-enrolled Black youth with a lifetime mental health diagnosis?

In this case-control study of 9625 youth, suicide risk was higher among Black youth with depression, psychosis, prior suicide attempts, psychiatric acute care, brain injury, family conflict, violence exposure, and placement in foster care or Medicaid eligibility due to disability status. Contextual-level risk was elevated in urban (vs rural) and moderate and high social vulnerability areas (vs low) and reduced in areas with moderate and high densities of religious institutions (vs low).

These findings suggest the need for testing effectiveness of multilevel suicide prevention strategies that address individual, family, and contextual factors for Black youth.

This case-control study examines individual-, family-, and contextual-level factors associated with suicide death among Black youth with a lifetime mental health diagnoses using US Medicaid data.

Suicide rates among Black youth have risen sharply in recent years, surpassing those of other racial and ethnic groups. However, research examining factors contributing to suicide in this population remains limited.

To examine individual-, family-, and contextual-level factors associated with suicide death among Black youth with a lifetime mental health diagnosis.

This population-based case-control study examined US Medicaid data of 875 Black youth who died by suicide between January 1, 2010, and December 31, 2019. Each suicide case was matched with 10 living controls (ie, 8750 individuals) on age, sex, and state. All cases and controls were Medicaid-enrolled and had a documented lifetime mental health diagnosis. Data were analyzed from March to December 2025.

Individual (demographic, clinical characteristics, service history), family (history of abuse and neglect, family relational problems, and economic and housing problems), and contextual variables (social vulnerability, urban-rural status, crime rates, religious institution density) were abstracted from Medicaid claims data and supplemented with county-level data from publicly available sources.

Suicide deaths, identified from National Death Index records. Hierarchical generalized estimating equations were fit to examine factors associated with suicide.

The total sample of 9625 individuals had a mean (SD) age of 18.9 (3.6) years and was primarily male (6950 [72.2%]). Factors associated with increased odds of suicide included foster care (aOR, 1.81 [95% CI, 1.34-2.44]) and disability status (aOR, 1.23 [95% CI, 1.01-1.49]) vs poverty enrollment in Medicaid, depression (aOR, 1.94 [95% CI, 1.59-2.38]) and schizophrenia or psychosis diagnoses (aOR, 3.52 [95% CI, 2.68-4.62]), prior deliberate self-harm (aOR, 11.01 [95% CI, 7.32-16.55]), prior acute mental health care (aOR, 2.20 [95% CI, 1.37-3.54]), brain injury (aOR, 4.41 [95% CI, 2.55-7.64]), violence exposure (aOR, 2.65 [95% CI, 1.51-4.65]), family relational problems (aOR, 2.27 [95% CI, 1.18-4.38]), or living in an urban community (aOR, 1.79 [95% CI, 1.40-2.29]) or in a moderate socially vulnerable county (aOR, 1.39 [95% CI, 1.13-1.73]) or high socially vulnerable county (aOR, 1.45 [95% CI, 1.17-1.80]). Factors associated with decreased odds included a diagnosis of anxiety (aOR, 0.70 [95% CI, 0.53-0.93]) and developmental disorders (aOR, 0.45 [95% CI, 0.29-0.69]) and living in a county with moderate (aOR, 0.78 [95% CI, 0.65-0.95]) or high (aOR, 0.65 [95% CI, 0.47-0.90]) rates of religious institutions. The highest population attributable risk (PAR) for suicide was prior deliberate self-harm (PAR, 56.4%; 95% CI, 53.5%-58.3%).

In this case-control study of Medicaid-enrolled Black youth with a lifetime mental health diagnosis, suicide risk was driven by a complex interplay of individual, family, and contextual factors. These results highlight the importance of culturally responsive, community-rooted, and equity-focused prevention strategies to reduce suicide risk in Black youth.