Suicidal Ideation and Suicidal Attempt in Spanish Adolescents: Risk Profiles Identified Through Decision Tree Analysis

Suicide is a major public health concern accounting for 800 000 deaths globally each year. Although there have been many advances in understanding suicide risk in recent decades, our ability to predict suicide is no better now than it was 50 years ago. There are many potential explanations for this lack of progress, but the absence, until recently, of comprehensive theoretical models that predict the emergence of suicidal ideation distinct from the transition between suicidal ideation and suicide attempts/suicide is key to this lack of progress. The current article presents the integrated motivational–volitional (IMV) model of suicidal behaviour, one such theoretical model. We propose that defeat and entrapment drive the emergence of suicidal ideation and that a group of factors, entitled volitional moderators (VMs), govern the transition from suicidal ideation to suicidal behaviour. According to the IMV model, VMs include access to the means of suicide, exposure to suicidal behaviour, capability for suicide (fearlessness about death and increased physical pain tolerance), planning, impulsivity, mental imagery and past suicidal behaviour. In this article, we describe the theoretical origins of the IMV model, the key premises underpinning the model, empirical tests of the model and future research directions.

Suicidality and Self-harm in Adolescents With Attention-Deficit/Hyperactivity Disorder and Subsyndromal ADHD

The present study evaluated sociodemographic and diagnostic predictors of suicidal ideation and attempts in a nationally representative sample of preadolescent youth enrolled in the Adolescent Brain Cognitive Development Study. Rates and predictors of psychiatric treatment utilization among suicidal youth also were examined. Eleven thousand eight hundred and seventy-five 9- and 10-year-old children residing in the United States were assessed. Children and their parents/guardians provided reports of children’s lifetime history of suicidal ideation, suicide attempts, and psychiatric disorders. Parents also reported on sociodemographic characteristics and mental health service utilization. Multivariate logistic regression analyses were employed to evaluate sociodemographic and diagnostic correlates of suicidal ideation, suicide attempts among youth with suicidal ideation, and treatment utilization among youth with suicidal ideation and suicide attempts. Lifetime prevalence rates were 14.33% for suicidal ideation and 1.26% for suicide attempts. Youth who identified as male, a sexual minority, or multiracial had greater odds of suicidal ideation, and sexual minority youth and youth with a low family income had greater odds of suicide attempts. Comorbid psychopathology was associated with higher odds of both suicidal ideation and suicide attempts. In youth, 34.59% who have suicidal ideation and 54.82% who had attempted suicide received psychiatric treatment. Treatment utilization among suicidal youth was lower among those who identified as female, Black, and Hispanic. Suicidal ideation and attempts among preadolescent children are concerningly high and targeted assessment and preventative efforts are needed, especially for males, racial, ethnic, and sexual minority youth, and those youth experiencing comorbidity.

Suicidal ideation is a prominent public health problem among junior middle school students. Previous researchers have explored the influence of parenting style on adolescents' suicidal ideation, but few researchers distinguished the influence of positive and negative parenting styles. The mediating effect of negative emotions between negative parenting styles and suicidal ideation and the moderating effect of hope among Chinese junior middle school students were focused on in this study. 877 junior middle school students in Hunan, Anhui, and Jiangxi provinces in China were investigated with the simplified Parenting Style Questionnaire, Positive and Negative Affect Schedule, Children's Hope Scale, and Self‐rating Idea of Suicide Scale. The theoretical models were tested through the PROCESS macro for SPSS. The results showed that: (1) Negative parenting styles had positive effects on suicidal ideation. (2) Negative emotions mediated the relationship between negative parenting styles and suicidal ideation. (3) Hope moderated the relationship between negative emotions and suicidal ideation. This study implies that we could start by improving adolescents' negative parenting styles and raising their level of hope to prevent and intervene in adolescents' suicidal ideation.

Consequences of Psychological Distress in Adolescents with Acne

A large body of research suggests that child maltreatment (CM) is associated with adolescent suicidal ideation and attempts. These studies, however, have not been critically examined and summarized in a manner that allows us to draw firm conclusions and make recommendations for future research and clinical work in this area. In this review, we evaluated all of the research literature to date examining the relationship between CM and adolescent suicidal ideation and attempts. Results generally suggest that childhood sexual abuse, physical abuse, emotional abuse, and neglect are associated with adolescent suicidal ideation and attempts across community, clinical, and high-risk samples, using cross-sectional and longitudinal research designs. In most studies, these associations remain significant when controlling for covariates such as youth demographics, mental health, family, and peer-related variables. When different forms of CM are examined in the same multivariate analysis, most research suggests that each form of CM maintains an independent association with adolescent suicidal ideation and suicide attempts. However, a subset of studies yielded evidence to suggest that sexual abuse and emotional abuse may be relatively more important in explaining suicidal behavior than physical abuse or neglect. Research also suggests an additive effect-each form of CM contributes unique variance to adolescent suicide attempts. We discuss the current limitations of this literature and offer recommendations for future research. We conclude with an overview of the clinical implications of this research, including careful, detailed screening of CM history, past suicidal behavior, and current suicidal ideation, as well as the need for integrated treatment approaches that effectively address both CM and adolescent suicidal ideation and suicide attempts.

Purpose: The purpose of this study was to investigate the combined influence of the frequency and the intensity of smoking on suicidal ideation and attempts in Korean high school students. Methods: This cross sectional study used secondary data from the 2014 Adolescent Health Behavior Online Survey. A total of 35,094 high school students were included in the study. The study set up two categories for the frequency of smoking - intermittent and daily - and another two for the intensity of smoking - heavy and light. Complex samples logistic regression was used to analyze the combined influence of smoking frequency and intensity on suicidal ideation and attempts. Results: Regardless of frequency and intensity, smoking was more likely to increase suicidal ideation and attempts than non-smoking. Among smokers, intermittent heavy smokers (suicidal ideation: Adjusted Odds Ratio [AOR]: 1.406, 95% Confidence Interval [CI]: 1.015~2.161, p=.012; suicidal attempts: AOR: 2.977, 95% CI: 1.814~4.886, p<.001) or daily heavy smokers (suicidal ideation: AOR: 1.274, 95% CI: 1.017~1.596, p=.035; suicidal attempts: AOR: 1.717, 95% CI: 1.250~2.359, p=.001) had significantly higher odds of suicidal ideation and attempts than intermittent light smokers. Conclusion: Based on the results, smoking prevention and cessation are essential to preventing suicides in adolescents. Especially, smoking intervention programs are needed to reduce smoking intensity in smokers.

After completing this article, readers should be able to: Most youth occasionally experience the blues, feel sad, or become irritable. Nevertheless, it is important to consider the possibility of a depressive disorder when a depressed or irritable mood is more than temporary, occurs in conjunction with other symptoms, or interferes with daily functioning. Major depressive disorder (MDD) is manifested by a depressed or irritable mood or diminished interest or pleasure that lasts for at least 2 weeks. This is accompanied by changes in cognitive and physical functioning. Dysthymic disorder (DD) is a less severe type of depression that involves chronic symptoms and lasts for at least 1 year. These specific types of depressive disorders are the focus of this article.Depressive disorders can be identified in children of all ages, but they become increasingly prevalent during adolescence. In fact, the peak ages of depressive symptom onset in lifespan studies are 15 to 19 years and 25 to 29 years. The sharpest rise in prevalence occurs among girls during adolescence and early adulthood. Approximately 2% of school-age children and 4% to 6% of adolescents struggle with MDD at any one point in time. Lifetime prevalence rates by late adolescence range between 20% and 25%.Prior to puberty, there is about a 1:1 gender ratio for depressive disorders. After puberty, this shifts to a 2:1 ratio of females to males, which continues throughout adulthood. A combination of hormonal and social changes during puberty may explain the differing rates of depression among males and females.Depression has a complex genetic and environmental basis. Adoption, twin, and family studies all point to the impact of genetic factors, which seem to establish a young person's biologic vulnerability for depression. The onset of a depressive episode, however, often is precipitated by difficult life events or stressful experiences such as a parental divorce, school change, or relationship breakup. Other environmental risk factors include maltreatment (sexual abuse, physical abuse, or neglect). The pathways to depression are complex and variable. Some depressive disorders are more biologic; others are more situational.The symptoms of MDD and DD, as outlined in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV; American Psychiatric Association, 1994), include changes in physical, cognitive, and emotional domains (Tables 1 and 2).In 1996, the World Health Organization ranked depression among the most disabling of all diseases in the world, leading all other disorders in "years lived with disabilities." The reasons for this are apparent when one considers the course of depressive illness. Approximately 70% of youth who have MDD experience another depressive episode within 5 years, and youth who have depressive disorders have a fourfold risk of an adult depressive disorder. Approximately 50% of children and adolescents who have MDD can be expected to have adult recurrences. Early onset and recurrences also have been described as a cause of treatment-resistant depression in later life, leading to multiple episodes that last longer, become more severe, and become more difficult to treat. These tend to be associated with more hospitalizations, job absenteeism, and impaired work performance.Depressive disorders in youth are associated with impaired functioning in several areas of daily living. These include strained family and peer relationships, school attendance difficulties, and academic performance problems. Affected youth often experience suicidal thoughts and are at increased risk for attempted and completed suicide.Early-onset bipolar disorder (BD) often presents as depressive symptoms, which can make it difficult to distinguish between bipolar and unipolar depression. BD is characterized by alternating periods of mania and depression. The inflated self-esteem, excess energy, and poor judgment that characterize a manic phase often result in dangerous activity and substantial social problems. Rapid cycling and mixed symptom states occur in subtypes of BD. Approximately 20% to 40% of children who have MDD eventually develop BD. Some clues to the risk for developing a manic or hypomanic episode include psychosis, psychomotor retardation, or a family history of BD.Another potential diagnostic dilemma occurs when a child or adolescent is abusing alcohol or drugs. Youth are not always forthcoming about such abuse, which may be associated with declining school performance, withdrawal from usual social activities, sleep disturbance, and negative moods. Careful questioning of the youth and parent/guardian is necessary to identify a substance use disorder in youth presenting with depressive symptoms. It can be equally challenging to identify a depressive disorder in youth initially identified for services because of problems related to alcohol or substance abuse.Most children and adolescents who are depressed also have a history of some other psychiatric or alcohol/drug use disorder. For example, 25% to 75% of depressed youth have one or more anxiety disorders, such as separation anxiety disorder or social phobia. Disruptive behavior disorders, such as attention-deficit disorder or oppositional defiant disorder, are also common, and substance abuse or dependence characterizes a significant minority of youth who are depressed. A gender difference exists in patterns of comorbidity. Girls more commonly have comorbid anxiety conditions; boys are more likely to have comorbid conduct disorders or substance use disorders.Children and adolescents rarely seek professional treatment. Thus, parents, teachers, pediatricians, and others who have regular contact with youth play critical roles in recognizing youth who are depressed. Few youth use the word "depressed"; even fewer report to someone that they may be experiencing a clinical depression. Therefore, it is helpful to ask youth about experiences of feeling down, "bad," miserable, bored, or irritated. Signs of clinical depression that often initially are visible to others include withdrawal from activities, decline in school performance, change in sleep patterns, and sadness or irritability.The United States Preventive Services Task Force recently recommended the use of two questions in screening for depression among adults: "Over the past 2 weeks, have you ever felt down, depressed, or hopeless?" and "Have you felt little interest or pleasure in doing things?" The Task Force concluded that evidence is inconclusive regarding the effectiveness of routine screening of children and adolescents, but these two questions may help clinicians detect primary symptoms of depression. More comprehensive screening instruments and diagnostic tools or a referral to a mental health professional should be considered if indicated. The Reynolds Adolescent Depression Inventory (RADS) and the Children's Depression Inventory (CDI) are screening tools used in some school and mental health clinics.Clinical interviews are the cornerstone of a comprehensive assessment and should include, at a minimum, interviews with the youth as well as the parent or guardian. In addition to gathering a complete history of presenting problems (onset, chronicity, severity, prior history of symptoms, and treatment), a full psychiatric interview is conducted to obtain information about possible comorbid conditions. For example, it is critical to ascertain whether psychotic features, disruptive behavior disorders, anxiety disorders, or substance abuse problems are present. Information also is gathered about the youth's medical, developmental, social, and educational histories as well as the family psychiatric history.Important sources of information may include school academic and attendance records; teacher reports; and appropriate biomedical, psychological, or other test findings. Standardized self-report questionnaires may permit youths to answer questions about current symptoms without directly verbalizing the extent of their emotional distress to an adult. This approach sometimes can facilitate honest reporting of the number and severity of depressive symptoms. If noted in a self-report questionnaire, critical items always should be followed up with direct inquiry by the clinician (eg, if a youth reports suicidal ideation).The initial goals of treatment are to ensure the youth's safety and develop an effective therapeutic alliance with the youth and parents. This alliance will facilitate ongoing communication and continuation of care. Consultation with teachers and other caregivers also is important. A focus on patient and family education and a collaborative approach to treatment planning can enhance the youth's adherence to treatment recommendations.Psychoeducation is a key component of the treatment. Beyond this, perspectives on the first line of treatment vary. The choice of whether to begin with psychotherapeutic or psychopharmacologic interventions or a combination depends on depression severity and chronicity, prior history of depressive episodes, likelihood of adherence, previous response to treatment, patient and family motivation for treatment, and availability of resources. Because of the psychological, environmental, and social problems associated with depression and its treatment, pharmacotherapy usually is not sufficient as the sole treatment. Attention to parental mental health and family stress as well as to strategies for helping parents manage the youth's irritability, isolation, or other problems should be included in psychotherapeutic interventions. These systemic concerns affect treatment adherence and ultimate outcomes.Psychoeducation addresses the signs and symptoms of depression; the importance of psychotherapy and psychiatric medication; and common misconceptions about the illness, therapy, or medications. It also is helpful to address the impact that depression has on school, social, and family functioning and the ways in which parents and teachers may aid in recovery. Parent and family education may increase adherence and reduce self-blame. Education of parents can help them identify their own mood disorders and potential treatment needs as well. Education also can reduce blame for symptoms such as irritability and anhedonia that may affect others.Controlled studies have documented the short-term effectiveness of cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) for depressed youth. Both generally are time-limited therapies that involve collaboration or guided discovery between the therapist and adolescent. CBT focuses on self-understanding of negative mood states and on the identification and modification of negative, distorted thought patterns. It also emphasizes problem-solving skills, communication skills, and the development of more adaptive behavior patterns. IPT strives to improve the youth's interpersonal functioning by improving self-understanding, problem-solving, communication, and coping in the realm of relationships. It focuses on a chosen interpersonal problem such as grief, a difficult role transition, an interpersonal conflict or role dispute, social skill deficits, or issues in step-parent families. Although randomized, controlled clinical trials have not been conducted for psychodynamic therapy with depressed youth, this approach may be useful. Family therapy is an important supplement to any of these approaches if difficulties in family communication and support are identified. Goals of family therapy may include improving family affective communication, increasing adaptive behaviors, and changing both interpersonal and family functioning.Selective serotonin reuptake inhibitors (SSRIs) are the antidepressants of choice for youth who require pharmacotherapy (American Academy of Child and Adolescent Psychiatry, 1998). The efficacy of the SSRI fluoxetine in reducing depressive symptom severity in children and adolescents has been demonstrated in two double-blind, randomized, placebo-controlled trials. Paroxetine also has demonstrated efficacy compared with imipramine and placebo in a double-blind, placebo-controlled comparison. Other antidepressant medications are not well studied. Dosing guidelines recommend starting with 10 mg fluoxetine and increasing to 20 mg. The maximum dose is 40 mg to 80 mg. When treating a child younger than 8 years of age, clinicians may want to start with 4 to 8 mg elixir of fluoxetine. However, the efficacy and safety data have been demonstrated only down to age 8 years. If there are problems with insomnia, appetite loss, or restlessness, paroxetine is a more sedating SSRI, and dosing guidelines are identical to those for fluoxetine. SSRIs should be discontinued if symptoms of mania appear. However, youth may benefit from treatment with an SSRI for an extended period before BD develops.An adequate trial of SSRIs is at least 4 to 6 weeks. If no or only minimal improvement is observed, a dose increase should be considered and medication continued for at least 4 to 6 additional weeks. If no improvement has been observed, alternative strategies should be considered, including a referral to a psychiatrist in cases of treatment-resistant depression. Additionally, if the pediatrician is not comfortable in the prescriber role, a psychiatric consultation or referral to a physician experienced in the use of medication is recommended. Frequent medication adjustments are ill-advised, and tapering of medications that have shorter half-lives (eg, paroxetine) is recommended. Obtaining serum levels rarely is necessary unless concerns arise about toxicity or compliance. Studies among adults suggest that the same doses used to treat MDD are efficacious for DD.Tricyclic antidepressants (TCAs) are not considered a first-line treatment for children and adolescents who are depressed, but they may be helpful in treating youth who have comorbid attention-deficit/hyperactivity disorder, enuresis, and narcolepsy as well as for augmentation purposes.In contrast to TCAs and monoamine oxidase inhibitors, SSRIs have a relatively safe adverse effects profile, are easily used (once daily), are suitable for long-term maintenance, and have a low lethality after overdose. Additional information on adverse effects, medication interactions, and the treatment of comorbid conditions is available in reviews of practice recommendations published by the American Academy of Child and Adolescent Psychiatry.ECT can be a useful adjunct for individuals whose depression is severe or life-threatening, who have not responded to other treatments, who cannot take antidepressant medications, and who may have psychotic depression. The decision to use ECT must be made carefully and usually requires the recommendation of more than one psychiatrist as well as a substantial discussion with the child's parent or guardian.Unless there are significant adverse effects, medication should be continued for 6 to 12 months if it is believed to help in the remission of depressive symptoms. The pharmacotherapy should be monitored monthly during this continuation phase. Psychotherapy is helpful during this phase to bolster coping skills and to address antecedents, stressors, and interpersonal conflicts that may have contributed to the onset of depression. Medication adherence also may be improved by psychotherapy.Once the patient's symptoms have remitted for 6 to 12 months, the maintenance phase of treatment may last from 1 year to indefinitely. The goals are to facilitate healthy development and to prevent relapse or recurrence. These may be accomplished through monthly or quarterly visits, depending on the severity and chronicity of the present episode, frequency of previous episodes, comorbid disorders, the patient's motivation, and contextual factors (eg, support systems, family stress, and psychopathology).The presence of comorbid conditions often predicts a poorer response to psychopharmacologic and psychosocial treatments. These conditions, such as anxiety, disruptive behavior, and substance use disorders, often persist after remission of the depressive symptoms and require targeted treatments. Because of time, cost, or the incompatibility of treatments, addressing all conditions simultaneously may be impossible. Hence, the clinician often must prioritize treatment goals and the sequence of interventions.A depressive disorder may be "treatment-resistant" because of an inadequate dosage or duration of medication trial, inadequate duration or "fit" with a particular psychotherapy, poor treatment adherence, complicating comorbidity, undetected BD, chronic or severe life events, misdiagnosis, or mistreatment. Psychopharmacologic strategies to address treatment-resistant depression should be applied systematically in conjunction with family education and support and include optimization, switching, augmentation, or combination. Consultation with a psychiatrist always is advised with treatment-resistant cases.If BD is present or is a possibility, a mood-stabilizing agent (eg, lithium carbonate, valproate, or carbamazepine) may be warranted, especially because antidepressants may induce mania in youths at risk for BD. Approximately 30% to 50% of adults experience modest antidepressant effects with mood stabilizers alone. Antidepressants may be useful adjuncts in such treatments. Psychotic depression may require a combination of antidepressants with antipsychotics or ECT. Neuroleptics should be tapered after psychotic symptoms remit due to the risk of tardive dyskinesia. Atypical antipsychotic medications may be preferred. However, the long-term effects of these medications have not been studied in youth.Suicide is the third leading cause of death among children and adolescents (National Center for Health Statistics, CDC, 2000). The suicide rate for ages 15 to 24 years is 11.1 per 100,000, which is much higher than the rate for youth between the ages of 5 and 14 years (0.8 per 100,000). The suicide rate for males in the 15- to 19-year age group is markedly higher than that for females (Table 3). Rates differ by racial and ethnic group. African-American youth have lower suicide rates than Caucasian youth, with the lowest adolescent suicide rate being that of African-American females. The highest suicide rate is that of Native American males.Although many youth who report suicidal thoughts or attempt suicide do not become suicide victims, these categories overlap substantially. For instance, having frequent thoughts of suicide is the best predictor of suicide attempts, and most youth who attempt suicide report a history of suicidal ideation. Furthermore, greater severity of reported suicidal thoughts increases the likelihood of a suicide attempt within the next year. Approximately 35% to 45% of adolescents who complete suicide have a positive history of suicide attempt. The prevalences of both self-reported suicidal ideation and suicide attempts are higher for adolescent females than for adolescent males (Table 3).Risk factors for completed suicide and suicidal behavior are similar in most respects. There are a few exceptions, however, such as the more specific relationship between availability of firearms and completed suicide. In this section, we review the primary risk factors for completed suicide (Table 4).A history of prior suicidal behavior is the strongest predictor of future suicidal behavior. Nonlethal suicidal gestures or self-inflicted harm, which sometimes are thought to be manipulative or attention-seeking, should not be taken lightly. Youth often can be poor judges of lethality, and what is believed to be a gesture actually may be accompanied by significant suicidal intent. It also may result in substantial physical harm or even suicide because of an error in knowledge or judgment (eg, potential lethality of acetaminophen overdose).Approximately 80% of youth who attempt suicide and 90% of youth suicide victims have histories of identifiable psychiatric or mental disorders. The most common types of psychopathology in these youth are depressive disorders, alcohol or substance abuse, conduct disorder or patterns of aggressive behavior, and anxiety disorders. Increased suicide risk is associated with conditions that often are refractory to treatment or present management problems. These include BD, a chronic depressive disorder comorbid with alcohol or substance abuse, and psychotic presentations.Depressive disorders are linked with increased risk for suicidal ideation, suicide attempts, and completed suicides (Table 5). In fact, suicidal ideation and behavior are common and often unrelenting problems among youth who have depressive disorders. Eighty-five percent of depressed youth report significant suicidal ideation, and 32% of depressed youth report one or more suicide attempts prior to adulthood. Retrospective studies have found that about 50% of adolescent suicides involve the consumption of alcohol, which increases impulsivity, impaired judgment, and mood changes.Environmental or family stress, especially a history of neglect or physical, emotional, or sexual abuse, are considered significant risk factors for suicidal behavior. Interpersonal conflict and loss (eg, fights, break-ups, deaths) also are risk factors. Additionally, hopelessness, impulsivity, aggressive behavior, and agitation are psychological characteristics associated with increased risk for suicidal behavior.Gay, lesbian, and bisexual adolescents are at increased risk for suicidal behavior. Recent general population surveys indicate that of these youth experience suicidal ideation, and have made one or more suicide attempts during the past year. of the risk factors in these youth are the same as those for youth. such as comorbid substance abuse and however, are more common among youth who have a In risk factors such as and are specific to those who negative within risk for anxiety, and suicide increases when a youth someone who suicide. In these at and and and social as well as at identification with the suicidal behavior are recommended. of suicide may suicide are to possible to reduce and to parents and to of youth to such are found more commonly in the of suicide victims than in the of other youth, including those of suicidal youth. The importance of suicidal youth's to firearms is by documented between more and in suicide as or should be from the of suicidal youth or monitored by parents and that if adolescents will suicidal and previous suicidal behavior. questions should address whether children or adolescents they not if they ever have thought about or to if they ever have thought about or to and if they have or such a in It is important to that an adolescent about suicidal thoughts or will not such or or increase the risk for suicidal behavior. inquiry regarding the chronicity, and of such thoughts is Standardized self-report such as the may permit the youth to answer without direct which can facilitate If critical items related to or planning and items significant of chronicity, severity, or always should be followed up with direct Other sources of information include reports from parents, teachers, or others who may have suicidal or such as with the assessment of depressive disorders, a comprehensive that from the youth and parent or is psychiatric or may be necessary for found to be at suicide generally are and and attempts that have significant lethality and that include taken to indicate as well as knowledge and planning and should be taken Furthermore, to safety requires of the child's and caregivers should be advised to especially firearms and medications, from the by young children should not be as For example, when a child it may not be behavior should be carefully for associated mood or other or are used in many The patient is to not to attempt suicide. Furthermore, the patient is to to contact the or other adult if or a suicidal or experiences suicidal intent. on these have the past with an increasing on the as an assessment The may current suicidal intent. It also information about the patient's to and to helpful It is useful to review what positive coping the youth and parent take in the of a suicidal This an for problem-solving and can the of some youth and to or the risk of suicidal behavior. It should be however, that not support the that such prevent they are not for comprehensive for a suicidal youth, suicide risk factors, including suicidal and behaviors, are monitored at of when with suicidal youth next at up on and information to the youth and parent or about easily management and regular patient with guidelines for to in population of suicidal youth is in of primary psychiatric comorbid conditions, the presence of complicating psychosocial and Therefore, the treatment should be on a comprehensive of psychopathology more suicide risk and factors.

Previous literature has demonstrated a strong association between cigarette smoking, suicidal ideation and suicide attempts. This association has not previously been examined in a causal inference framework and could have important implications for suicide prevention strategies. We aimed to examine the evidence for an association between smoking behaviours (initiation, smoking status, heaviness, lifetime smoking) and suicidal thoughts or attempts by triangulating across observational and Mendelian randomisation analyses. First, in the UK Biobank, we calculated observed associations between smoking behaviours and suicidal thoughts or attempts. Second, we used Mendelian randomisation to explore the relationship between smoking and suicide attempts and ideation, using genetic variants as instruments to reduce bias from residual confounding and reverse causation. Our observational analysis showed a relationship between smoking behaviour, suicidal ideation and attempts, particularly between smoking initiation and suicide attempts (odds ratio, 2.07; 95% CI 1.91-2.26; P < 0.001). The Mendelian randomisation analysis and single-nucleotide polymorphism analysis, however, did not support this (odds ratio for lifetime smoking on suicidal ideation, 0.050; 95% CI -0.027 to 0.127; odds ratio on suicide attempts, 0.053; 95% CI, -0.003 to 0.110). Despite past literature showing a positive dose-response relationship, our results showed no clear evidence for a causal effect of smoking on suicidal ideation or attempts. This was the first Mendelian randomisation study to explore the effect of smoking on suicidal ideation and attempts. Our results suggest that, despite observed associations, there is no clear evidence for a causal effect.

Peer victimization is related to an increased chance of suicidal ideation and suicide attempts among children and adolescents. OBJECTIVE To examine the relationship between peer victimization and suicidal ideation or suicide attempts using meta-analysis. DATA SOURCES Ovid MEDLINE, PsycINFO, and Web of Science were searched for articles from 1910 to 2013. The search terms were bully*, teas*, victim*, mobbing, ragging, and harassment in combination with the term suic*. Of the 491 studies identified, 34 reported on the relationship between peer victimization and suicidal ideation, with a total of 284,375 participants. Nine studies reported on the relationship between peer victimization and suicide attempts, with a total of 70,102 participants. STUDY SELECTION Studies were eligible for inclusion if they reported an effect size on the relationship between peer victimization and suicidal ideation or suicide attempt in children or adolescents. Two observers independently coded the effect sizes from the articles. Data were pooled using a random effects model. MAIN OUTCOMES AND MEASURES This study focused on suicidal ideation and suicide attempts. Peer victimization was hypothesized to be related to suicidal ideation and suicide attempts. RESULTS Peer victimization was found to be related to both suicidal ideation (odds ratio, 2.23 [95% CI, 2.10-2.37]) and suicide attempts (2.55 [1.95 -3.34]) among children and adolescents. Analyses indicated that these results were not attributable to publication bias. Results were not moderated by sex, age, or study quality. Cyberbullying was more strongly related to suicidal ideation compared with traditional bullying. CONCLUSIONS AND RELEVANCE Peer victimization is a risk factor for child and adolescent suicidal ideation and attempts. Schools should use evidence-based practices to reduce bullying.

School factors play important roles in adolescent suicide. However, little is known about how school climate is associated with adolescent suicide. This study examined the relationship between perceived school climate and adolescent suicidal ideation and suicide attempts, and whether these relations were explained by adolescent sleep quality. A total of 1529 Chinese adolescents (mean age = 14.74 years; 52% boys) participated in the study. They provided self-report data on control variables, perceived school climate, sleep quality, suicidal ideation, and suicide attempts. After controlling for sex, age, family structure, socioeconomic status, and parent-adolescent attachment, we found that perceived school climate negatively predicted adolescent suicidal ideation (odds ratio [OR] = 0.66, p < .001) and suicide attempts (OR = 0.72, p < .001). Moreover, perceived school climate positively predicated adolescent sleep quality (β = 0.13, p < .001), which in turn, negatively predicted adolescent suicidal ideation (OR = 0.75, p < .001) and suicide attempts (OR = 0.76, p < .001). These findings, although cross-sectional, indicate that perceived school climate plays an important role in adolescent suicidality. Moreover, the relation between perceived school climate and adolescent suicidality was largely mediated by adolescent sleep quality.

Understanding the Health and Well-Being of Early Adolescents Throughout the World: Findings From the 2017–2018 Survey of Health Behavior in School-Aged Children

A network analysis of symptom-level associations between suicidality, depression and anxiety in Spanish adolescents.

Objective:Although suicide is a serious public health concern for adolescents, there is a lack of studies that explore its risk factors in the Republic of Korea. The present study aims to investigate risk factors associated with suicidal behaviors in Korean adolescents.Methods:Participants consisted of 2258 middle and high school students who completed a series of questionnaires regarding suicide ideation or attempts, non-suicidal self-injuries, depression, impulsivity, drinking behaviors, and negative life events, including peer bullying.Results:Among the participants, 8.3% of students reported suicide ideation, while 3.2% reported a history of a suicide attempt in the past 12 months. Depression, peer-victimization, internet-related delinquency, and positive attitudes toward suicide were associated with suicidal ideations and attempts. Adverse life events were also associated with suicide ideation, but not attempts, while not living with both parents and poor family relationships were associated with suicide attempts, but not ideations. Non-suicidal self-injuries were associated with both suicide ideations and attempts. Students with suicidal ideations and attempts can be differentiated depending on the presence of self-injury.Conclusion:In addition to depression or behavioral problems, non-suicidal self-injuries and lack of support from family may also play significant roles in suicide attempts in adolescents. To facilitate the prevention of suicide in adolescents, longitudinal studies should be followed to confirm the risk factors identified in this study.

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessLong-Term Study Backs Link Between Smoking, SuicidalityJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:15 Apr 2005https://doi.org/10.1176/pn.40.8.00400052While Americans worry about whether cigarette smoking will cause lung cancer, perhaps they should also pay attention to a lesser-known risk factor for the habit—suicide. Epidemiological studies going back at least a quarter century have linked cigarette smoking with suicide. And now another large epidemiological study does as well.This latest investigation was headed by Naomi Breslau, Ph.D., a professor of epidemiology at Michigan State University. Results appeared in the March Archives of General Psychiatry.In 1988, Breslau and her colleagues selected some 1,000 young adults to participate in their study. All were members of a health maintenance organization in the Detroit area. All were interviewed at baseline and at three, five, and 10 years after the study started. During each interview, their psychiatric health, smoking habits, and occurrence of suicidal thoughts and of suicidal attempts since the last interview were ascertained.As it turned out, subjects reported only 19 suicide attempts during the 10-year study period. Since 19 suicide attempts were not enough for a meaningful statistical analysis, Breslau and her team decided to lump suicidal attempts and suicidal thoughts together. Combining these gave 17 suicide attempts with the reporting of suicidal thoughts; two suicide attempts without the reporting of suicidal thoughts; and 130 suicidal thoughts without suicide attempts, for a total 132 suicidal thoughts and/or attempts.Breslau and her colleagues then attempted to see whether smoking at baseline, at the three-year assessment, and at the five-year assessment could be statistically linked with the combined number of suicidal thoughts or attempts during the subsequent study periods.The answer was yes. Compared with subjects who had never smoked, current smokers (those who had smoked during the past 12 months) were at a statistically significant increased risk of suicidal thoughts or attempts. In contrast, past daily smokers were not at increased risk for subsequent occurrence of suicidal thoughts or attempts.Moreover, this link between current cigarette smoking and suicidal thoughts or attempts held even when potentially confounding factors—prior suicidal thoughts or attempts, current or past major depression, and current or past substance abuse—were taken into consideration.And even though the study results did not find current cigarette smoking to be as grave a risk factor for suicidal thoughts or attempts as prior suicidal thoughts or attempts, or current or past major depression, they do suggest some practical implications.“Clinical psychiatrists should always be concerned and inquire about suicidality, self-destructive thoughts, et cetera,” Glenn Davis, M.D., a professor of psychiatry at Michigan State University and one of the study authors, said in an interview. “But with added knowledge that there is a connection between smoking and risk for suicidal behavior, they should be particularly sensitive to smoking history in their evaluation of patients.”“By highlighting current smoking, [this study further reinforces] the benefits of smoking cessation,” Donald Klein, M.D., a professor of psychiatry at Columbia University, pointed out to Psychiatric News.How current cigarette smoking might trigger suicidal thoughts or attempts is not known. Yet if it does play a causal role, Breslau and her team suspect that it may do so via an intermediary culprit—the enzyme monoamine oxidase (MAO), which is found in the liver and the central nervous system. It is crucial to the functions of the neurotransmitter serotonin. Low levels of MAO have been found in blood cells of current cigarette smokers, but not in those of ex-smokers, and low blood-cell levels of MAO in turn have been linked with violence and suicide.This investigation has several advantages over past ones on the subject. It took major depression, a well-established risk factor for suicide, into consideration, and it was quite sophisticated in design. Klein explained that it “incorporated major methodological advances by using prospective multiwave longitudinal psychiatric diagnoses in estimating whether smoking independently increases suicide-related behaviors.”The study had a weakness, however, which Breslau and her group acknowledged in their report: The researchers did not gather data about subjects' completed suicides, only about their suicidal thoughts and attempts.The study was funded by the National Institute of Mental Health.An abstract of “Smoking and the Risk of Suicidal Behavior” is posted online at<http://archpsyc.ama-assn.org/cgi/content/abstract/62/3/328>.▪ Arch Gen Psychiatry 2005 62 328 ISSUES NewArchived