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

Importance: 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. Objective: To examine individual-, family-, and contextual-level factors associated with suicide death among Black youth with a lifetime mental health diagnosis. Design, Setting, and Participants: 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. Exposures: 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. Main Outcomes and Measures: Suicide deaths, identified from National Death Index records. Hierarchical generalized estimating equations were fit to examine factors associated with suicide. Results: 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%). Conclusions and Relevance: 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.