Community Firearm Violence, Youth Depression, and Suicide Risk in Philadelphia: 2017–2024

OBJECTIVES: Youth suicide and depression rates increased during the COVID-19 pandemic. In Philadelphia, firearm violence surged and has since declined to pre-pandemic levels. We examined whether youth depression and suicide risk also declined and whether community firearm violence moderated these trajectories, given its documented associations with trauma and stress in youth. METHODS: This cross-sectional study examined 71 663 well visits among youth aged 12 to 18 years in a pediatric primary care network in Philadelphia, 2017 to 2024. Youth were screened for depression and suicidality using the Patient Health Questionnaire, modified for teens. Three pandemic eras were defined by stay-at-home orders and the World Health Organization's declaration ending the global emergency. Neighborhoods were classified as firearm violence hot, neutral, and cold spots based on cumulative police-reported shootings. Period differences in mental health outcomes were evaluated using models accounting for patient clustering and interaction terms testing moderation by community violence. RESULTS: Among 35 137 patients (50% female, 67% non-Hispanic Black), community firearm violence moderated changes in youth suicide risk from the pre- to post-pandemic period: risk declined in cold spots (-2.2 percentage points [pp] [95 % CI -3.9 to -0.4]) but increased in neutral (+0.9 pp [0.1-1.6]) and hot spots (+2.0 pp [0.3-3.7]). Overall, suicide risk remained elevated post-pandemic (10.8% vs 9.6%, +1.1 pp [1.1-1.2]), particularly among non-Hispanic Black and Medicaid-insured youth, whereas depression returned to pre-pandemic levels (7.6% vs 7.3%). CONCLUSIONS: After the pandemic, suicide risk remained elevated among youth in areas with high community firearm violence. Beyond universal screening, addressing persistent pandemic-related stressors within the context of community firearm violence is critical for improving youth mental health.