Documentation of Psychiatric Disorders Among U.S. Adolescents Who Died by Firearm Suicide: A Population-Based CDC WONDER Analysis, 2018–2024

Background Mortality records may capture the mechanism of adolescent suicide more consistently than the psychiatric history preceding it. We examined how frequently psychiatric disorders were documented among U.S. adolescents who died by firearm suicide and whether documentation varied across demographic and firearm-mechanism groups. Methods We conducted a population-based cross-sectional analysis of CDC WONDER Multiple Cause of Death data from 2018–2024. We identified U.S. adolescents aged 10–19 years who died by firearm suicide (ICD-10 X72–X74). The primary outcome was documentation of any mental or behavioral disorder (F01–F99) as a multiple cause of death. Secondary outcomes included mood disorders (F30–F39), psychoactive substance-use disorders (F10–F19), and neurotic, stress-related, and somatoform disorders (F40–F48). Documentation was compared by age, sex, race/ethnicity, and firearm mechanism. Temporal trends were assessed using Poisson/negative binomial regression. Results Among 8,885 adolescent firearm-suicide deaths, only 386 (4.34%; 95% CI, 3.93%–4.79%) had a documented psychiatric disorder. Mood disorders accounted for 229 cases (2.58% of all deaths; 59.33% of documented psychiatric cases), while psychoactive substance-use disorders were documented in 29 (0.33%). No neurotic, stress-related, or somatoform disorders were documented. Psychiatric documentation differed significantly by age (p < 0.001) and race (p < 0.001): no psychiatric disorders were documented among 1,378 decedents aged 10–14 years or among 1,202 Black decedents in the available race-stratified data, compared with documentation among 5.14% of those aged 15–19 years and 4.83% of White decedents. Documentation did not differ by sex (4.42% vs 3.85%; p = 0.408) and showed no significant annual change (p = 0.461). Firearm-suicide mortality likewise showed no significant temporal trend (IRR, 0.991; p = 0.962). Conclusions Psychiatric disorders were documented in fewer than 1 in 20 adolescent firearm-suicide deaths, highlighting the limited psychiatric information captured in mortality records. The complete absence of documented psychiatric disorders among younger adolescents and Black decedents is particularly notable and may reflect differences in diagnostic recognition, access to clinical records, informant reporting, or death-investigation practices rather than absence of psychiatric morbidity. These findings highlight a critical surveillance blind spot: absence of documentation should not be interpreted as absence of psychiatric risk. More standardized approaches to capturing psychiatric history during adolescent suicide investigations and linking mortality data with clinical records may improve surveillance and identify populations whose psychiatric risk is being missed.