Lifetime Suicide Plans Research Articles

Predictors of suicidal behaviors among school-going adolescents: a cross sectional study in Indonesia

BackgroundAdolescents are a high-risk age group for committing suicide, and the risk substantially increases from early to late adolescence. Adolescence also serves as critical time period for early detection and intervention to prevent suicidal behaviors. This study aimed to assess the prevalence of suicidality and identify significant predictors of suicidality among adolescents.MethodsA cross-sectional observational study was conducted between January-December 2023. Adolescents aged 14–18 years old (n = 2317) were consecutively recruited from 15 high schools across four provinces on Java Island in Indonesia. Self-reported validated instruments in Indonesian were used to assess sociodemographic profiles, self-esteem (RSES), hopelessness (BHS), loneliness (ULS-3), perceived social support (MSPSS), depression (PHQ-9), resilience (CD-RISC-10), suicidality (SBQ-R). With adjusted odds ratio (AOR) and 95% confidence interval (CI), binary logistic regression analysis was used to determine significant predictors of suicidality.ResultsThe prevalence of lifetime suicide ideation was 26.5%, lifetime suicide plans were 18.2%, lifetime suicide threat was 14.1%, and lifetime suicide attempt was 4.4%. The prevalence of 12-month suicide ideation was 43.1%. The following variables were identified and significantly associated with suicidality (p < 0.05): female students (AOR = 1.912; 95%CI:1.507–2.425), chronic illness (AOR = 2.886; 95%CI:1.545–5.389), low resilience (AOR = 1.347; 95%CI:1.036–1.750), low self-esteem (AOR = 2.020; 95%CI:1.578–2.585), low family support (AOR = 3.532; 95%CI:2.486–5.017), loneliness (AOR = 1.611; 95%CI:1.211–2.143), depression (AOR = 4.882; 95%CI = 3.861–6.175), and hopelessness (AOR = 1.602; 95%CI:1.154–2.224). Nagelkerke R square was 0.364 indicating the regression model explained 36.4% of variance in suicidality.ConclusionsOur study revealed several significant predictors of suicidality among adolescents which can be targeted to develop suicide prevention strategies.

Fear of detachment from mobile phone: nomophobia and suicidality among Malaysian university students before and during the COVID-19 pandemic

ABSTRACT The attachment to mobile devices during the COVID-19 pandemic has led to the possibility of increased nomophobia, which is the intense fear of losing access to one’s mobile device. Therefore, this study aimed to determine if nomophobia was independently associated with suicidality before and during the COVID-19 pandemic among university students in Malaysia. This cross-sectional study had two-time points in data collection: one year before and one year into the COVID-19 pandemic. N = 806 university students aged ≥ 18 years completed an online questionnaire comprising the Nomophobia Questionnaire, Multidimensional Scale of Perceived Social Support, and the Suicidal Behaviors Questionnaire-Revised. A multiple logistic regression (controlling for gender, age, and social support) was conducted to determine the association between nomophobia and suicidality before and during the COVID-19 pandemic. The prevalence of severe nomophobia before and during the COVID-19 pandemic was 15.7% and 35.6% respectively. The level of nomophobia was significantly higher during the COVID-19 pandemic compared to pre-pandemic. Pre-pandemic, there were no significant associations. During the pandemic, participants with moderate (aOR 3.09, 95% CI [1.14–8.40], p = .027) and severe (aOR 3.57, 95% CI [1.25–10.20], p = .018) nomophobia had higher odds of suicide plan. During the pandemic, moderate and severe nomophobia were independently associated with more than three times higher odds for a lifetime suicide plan. Our study findings carry implications for the well-being of university students.

Suicidal Thoughts and Behaviors in Older U.S. Military Veterans: Results From the National Health and Resilience in Veterans Study

To identify the prevalence and correlates associated with suicidal thoughts and behaviors (STBs) in a nationally representative sample of older (55+) US military veterans. Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (N=3,356; mean age=70.6). Self-report measures of past-year suicidal ideation (SI), lifetime suicide plan, lifetime suicide attempt(s), and future suicide intent were examined in relation to sociodemographic, neuropsychiatric, trauma, physical health, and protective factors. A total of 6.6% (95% CI=5.7%-7.8%) of the sample endorsed past-year SI, 4.1% (CI=3.3%-5.1%) a lifetime suicide plan, 1.8% (CI=1.4%-2.3%) a lifetime suicide attempt, and 0.9% (CI=0.5%-1.3%) future suicide intent. Higher levels of loneliness and lower levels of purpose in life were most strongly associated with past-year SI; lifetime history of major depressive disorder with suicide plan and suicide attempt; and frequency of past-year SI and more negative expectations regarding emotional aging with future suicide intent. These findings provide the most up-to-date nationally representative prevalence estimates of STBs among older military veterans in the United States. Several modifiable vulnerability factors were found to be associated with suicide risk in older US military veterans, suggesting that these factors may be targets for intervention in this population.

Investigation of the Subtypes of Nonsuicidal Self-Injury Based on the Forms of Self-Harm Behavior: Examining Validity and Utility via Latent Class Analysis and Ecological Momentary Assessment.

This study aimed to empirically derive and validate subtypes of nonsuicidal self-injury (NSSI) based on the forms of self-harm behavior. Sixty young adults who exhibited repetitive NSSI completed a clinical interview and baseline measures, followed by a two-week ecological momentary assessment (EMA). A latent class analysis was administered to identify NSSI subtypes based on the forms of self-harm behavior. The subtypes were then compared to baseline clinical and EMA variables, including emotions and urges to self-harm. The best-fitting model supported two subtypes: 1) substance abuse and suicide attempt subtype and 2) cutting and scratching subtype. The substance abuse and suicide attempt subtype reported a higher rate of engaging in lifetime suicide plans and suicide attempts and a higher number of lifetime suicide attempts. They also showed significantly higher severity of self-harm behavior, borderline personality traits, anger, posttraumatic symptoms, and difficulties in emotion regulation when compared to the cutting and scratching subtype. However, there was no inter-subtype difference in self-esteem. In the EMA data, anger toward others, feeling of rejection, loneliness, and helplessness were significantly high in the substance abuse and suicide attempt subtype. The variability of anger toward others was also higher in this subtype compared to the cutting and scratching subtype. Finally, in the two-week research period, the substance abuse and suicide attempt group showed a higher rate of reported urges to self-harm with or without suicidal intent. Findings support the validity of the subtypes based on the forms of self-harm behavior, suggesting the clinical utility of addressing heterogeneity within individuals exhibiting self-harm for assessment and treatment.

Disparities in Mental Health and Health Risk Behaviors for LGBT Veteran Subgroups in a National U.S. Survey.

Purpose: This study examined differences in mental health and health risk behaviors across sexual orientation and gender identity among U.S. veterans. Methods: Veterans were recruited through targeted social media advertising, community organizations, and listservs to complete an online survey (N = 1062). Generalized linear regression was used to evaluate differences in outcomes between subgroups, which included cisgender heterosexual men and women, lesbian women, gay men, bisexual men and women, transgender men and women, and veterans with other gender identities. Results: Transgender men and women reported a significantly higher prevalence of lifetime suicide plans and attempts compared to all other subgroups within the respective genders. Beyond this finding, patterns of all outcomes varied by gender. Compared to other subgroups of men, transgender men reported higher prevalence of posttraumatic stress disorder, whereas cisgender gay men reported higher prevalence of lifetime cocaine use and positive human immunodeficiency virus (HIV) status. Within the women subgroups, all LGBT subgroups reported higher prevalence of lifetime smoking and past-year marijuana use compared to heterosexual women. Cisgender lesbian women also reported higher prevalence of past-month heavy episodic drinking, and cisgender bisexual women reported higher prevalence of lifetime cocaine and stimulant use compared to other groups. Conclusion: Transgender women and men reported significantly higher prevalence of lifetime suicide plans and attempts than other groups, highlighting this as an area in need of urgent public health attention. Other disparity patterns indicated the importance of examining subgroups within the LGBT veteran community.

Suicidal behaviors among Bangladeshi university students: Prevalence and risk factors

BackgroundBangladeshi university students are considered to be highly suicide-prone compared to other populations and cohorts. However, no prior epidemiological studies have assessed the suicidality (i.e., past-year suicidal ideation [SI], lifetime suicide plan [SP], and lifetime suicide attempt [SA]) among Bangladeshi students, including the variables such as past-year stressful life events and family mental health history. This is arguably a major knowledge gap in the country. Therefore, the present study investigated the prevalence and associated risk factors for suicidal behaviors among Bangladeshi university students.MethodsA cross-sectional study was conducted utilizing a convenience sampling method among a total of 1844 university students between October and November 2019. Data were collected based on the information related to socio-demographics, perceived health-related questions, past-year stressful life events, family mental health history, and suicidal behaviors (i.e., SI, SP, and SA). Chi-square tests and binary logistic regressions were used to analyze the data utilizing SPSS statistical software.ResultsThe prevalence of past-year suicidal ideation, lifetime suicide plans, and suicide attempts were 13.4%, 6.0%, and 4.4%, respectively. Females reported significantly higher suicidal behavior than males (i.e., 20.6% vs.10.2% SI; 9% vs. 4.6% SP; and 6.4% vs.3.6% SA). Risk factors for SI were being female, year of academic study, residing in an urban area, using psychoactive substances, experiencing both past year physical and mental illness, experiencing any type of stressful past-year life events, experiencing campus ragging (i.e., senior students abusing, humiliating and/or harassing freshers or more junior students), experiencing family mental illness history, and having family suicide attempt history. SP was associated with several factors including being female, year of academic study, using psychoactive substance, experiencing both past-year physical and mental illness, and experiencing any type of stressful past-year life events. Risk factors for SA were being female, year of academic study, using psychoactive substances, experiencing past-year mental illness, experiencing any type of stressful past-year life events, and having family suicide attempt history.ConclusionsUniversity students appear to be a vulnerable group for experiencing suicidal behaviors. The present findings warrant rigorous action and early intervention programs such as counseling and other mental health professional services by university authorities. Longitudinal studies are highly recommended involving countrywide representative samples.

Prevalence, Correlates, and Treatment of Suicidal Behavior in US Military Veterans: Results From the 2019-2020 National Health and Resilience in Veterans Study.

Objective: US military veterans have high rates of suicide relative to civilians. However, little is known about the prevalence and correlates of suicidal behaviors in the general US veteran population.Methods: Data were from the National Health and Resilience in Veterans Study, a representative survey of US veterans conducted in 2019-2020 (n = 4,069). Analyses (1) estimated the prevalence of current suicidal ideation, lifetime suicide plans, and lifetime suicide attempts; (2) identified associated sociodemographic, military, DSM-5 psychiatric, and other risk correlates; and (3) examined mental health treatment utilization among veterans with suicidal ideation, suicide plans, or suicide attempts.Results: The prevalence of current suicidal ideation, lifetime suicide plans, and lifetime suicide attempts was 9.0%, 7.3%, and 3.9%, respectively. Suicidal behaviors were most prevalent among veterans aged 18-44 years, with 18.2%, 19.3%, and 11.1%, respectively, endorsing suicidal ideation, suicide plans, and suicide attempts. Major depressive disorder (MDD), age, posttraumatic stress disorder, and adverse childhood experiences (ACEs) emerged as the strongest correlates of suicidal ideation and suicide plans, while MDD, age, alcohol use disorder, and ACEs were the strongest correlates of suicide attempts. Only 35.5% of veterans with current suicidal ideation were engaged in mental health treatment, with veterans who used the US Veterans Administration (VA) as their primary source of health care more than twice as likely as VA non-users to be engaged in such treatment (54.7% vs 23.8%).Conclusions: Suicidal behaviors are highly prevalent among US veterans, particularly among young veterans. Results suggest that nearly two-thirds of veterans with current suicidal ideation are not engaged in mental health treatment, signaling the need for enhanced suicide prevention and outreach efforts.

Examination of characteristics of ruminative thinking as unique predictors of suicide-related outcomes

Rumination, a passive, repetitive perseveration on the causes, meaning, and consequences of one's distress, has been linked to suicidal ideation and behavior. Less is known, however, about which specific characteristics of rumination confer risk for suicide-related outcomes. This study examined associations between four features of rumination—frequency, duration, perceived controllability, and content—and current suicidal ideation, lifetime suicide plans, and lifetime suicide attempts. A sample of 548 adults (53.6% female, Mage = 36.54 years, 80.8% White/European American) recruited via Amazon's MTurk completed a battery of self-report measures online. The perceived controllability of rumination was uniquely associated with suicidal ideation, plans, and attempts, controlling for other characteristics of rumination, generalized worry, and demographic characteristics. Perceived controllability was also related to lifetime suicide plans and attempts above and beyond current suicidal ideation. Interpersonal and health-related content areas were also related to suicide-related outcomes, though these effects were inconsistent across outcome. Overall, perceived controllability over one's thoughts may be a key factor that confers risk along the suicidality continuum. Future research should replicate and extend these findings in diverse populations, using longitudinal designs, and with a variety of methodologies.

Premenstrual dysphoric symptoms and lifetime suicide experiences in patients with mood disorder

BackgroundPremenstrual dysphoric symptoms (PMDS) commonly co-occurred with mood disorders and correlated with suicide experiences in women. This study aims to examine the associations between PMDS and lifetime suicide experiences in patients with mood disorders. MethodsParticipants were recruited from outpatient settings of two medical centers and one psychiatric hospital in Taiwan. Women aged 18–65 in non-acute state of major depressive disorder or bipolar affective disorder were recruited. PMDS and lifetime suicide experiences were defined by the Schedule for Affective Disorder and Schizophrenia-Lifetime. Lifetime suicide experiences were defined as no suicide experience, suicide plans only and suicide attempts. ResultsA total of 383 women participated in this study (54.8% of them were diagnosed with major depressive disorder), and 13.8% were diagnosed with PMDS. The prevalence of patients with lifetime suicide plans only and lifetime suicide attempts were 15.9% and 39.7%, respectively. In the univariate analysis, PMDS was correlated with lifetime suicide experience. After controlling for covariates, PMDS was a risk indicator for lifetime suicide attempts (OR: 3.46, 95% CI: 1.43–8.38) but not for suicide plans only (OR: 0.93, 95% CI: 0.28–3.11). ConclusionsPMDS correlated with lifetime suicide experiences in women with non-acute mood disorders. In particular, PMDS exhibited as an independent correlate for lifetime suicide attempts.

Tobacco smoking in non-psychotic patients with suicidal ideation

IntroductionTobacco smoking (TS) is a major public health concern worldwide because of its association with a number of unfavorable health-related outcomes. According to recent studies TS negatively affects both physical and mental health. Suicidal ideation (SI) is more prevalent in people with mental disorders than in the general population. Factors associated with the transition from SI to suicide attempt (SA) should be detected to prevent suicide in this high-risk population.ObjectivesThe aim of the study is to evaluate the influence of tobacco smoking on risk of lifetime suicide plan (SP), SA and nonsuicidal self-injury (NSSI) in patients with nonpsychotic mental disorders (NPMD) and SI.MethodsFour hundred and 78 consecutive patients with NPMD and SI were included into the study. All patients were evaluated by a psychiatrist, underwent Self-Injurious Thoughts and Behavior Interview as well as semi-structured interview designed to gather information on demographic and biographical features. Mann-Whitney, Fishers exact test, chi-square test and stepwise logistic regression were used as statistical methods.ResultsThree hundred and 24 (67.8%) patients have smoked at least 100 cigarettes in their entire life. No differences were found between smokers and non-smokers in terms of age, gender, educational and occupational statuses as well as age at onset of self-injurious thoughts and behavior, and total number of SP, SA and NSSI (all: p&gt;0.05). The lifetime smokers were at higher risk of SA (OR=2.379; 95% CI 1.58-3.581: p&lt;0.001) and NSSI (OR=1.591; 95% CI 1.064-2.38: p=0.024).ConclusionsLifetime smoking in patients with NPMD and SI is associated with SA and NSSI.

Moral injury and suicidal behavior among US combat veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study.

Recent research suggests that exposure to potentially morally injurious experiences (PMIEs) may be associated with increased risk for suicidal behavior among US combat veterans, but population-based data on these associations are scarce. This study examined the association between PMIEs with current suicidal ideation (SI), lifetime suicide plans (SP), and suicide attempts (SA) in a contemporary, nationally representative sample of combat veterans. Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US combat veterans (n = 1321). PMIEs were assessed using the Moral Injury Events Scale (MIES). Multivariable logistic regression analyses were conducted to examine associations between MIES total scores and specific types of PMIEs with suicidal behavior. Thirty-six point three percent of veterans reported at least one PMIE. Perceived transgressions by self, others, and betrayal were associated with SI, SP, and SA (odds ratios [ORs] = 1.21-1.27, all p s < .05), after adjusting for sociodemographic, trauma, and psychiatric characteristics. MIES total scores were significantly, albeit weakly, associated with SP (OR = 1.03, p < .01), but not SI/SA. Depression, posttraumatic stress disorder (PTSD), and age emerged as the strongest correlates of SI/SP/SA (14.9%-38.1% of explained variance), while PMIEs accounted for a comparatively modest amount of variance (3.3%-8.9%). Reports of potentially morally injurious experiences are prevalent among US combat veterans, and associated with increased risk for suicidal behavior, above and beyond severity of combat exposure, PTSD, and depression. Implications for clinical practice and future research are discussed, including the need for methodological advancements in the measurement of moral injury.

Sexual orientation and prevalence of mental health difficulties among emergency services employees

BackgroundLGBQ+ people (Lesbian, Gay, Bisexual, Queer) are at-risk of discrimination and developing mental health issues within general populations. Limited research has assessed their mental health in emergency services occupations, a population which are known to experience poorer mental health. The current study explores the extent to which sexual orientation is associated with higher rates of mental health issues among emergency personnel. MethodsA stratified random sample of employees from twenty-nine police (N = 8,088), ambulance (N = 3,473), and fire and rescue (N = 2,975) agencies from around Australia participated in a cross-sectional mental health survey (N = 14,536, male = 64.2%, 42.7% over 45 years of age, heterosexual = 92.7%). ResultsEmployees with a bisexual/pansexual orientation or those who were not sure about their sexual orientation were significantly more likely to report suicidal thoughts, suicide plans, psychological distress, and illicit drug use when compared with heterosexual employees. LGBQ+ employees reported significantly higher rates of lifetime suicide plans and attempts. Specifically, LGBQ+ fire and rescue personnel were roughly six times more likely to report lifetime suicide attempts, and approximately five times more likely to use illicit drugs weekly than their heterosexual colleagues in the fire and rescue sector. Female LGBQ+ personnel were significantly less likely to consume illicit drugs weekly and monthly than male LGBQ+ personnel. ConclusionsEmergency services personnel are already at-risk of developing pervasive mental health difficulties. It is important that organisations foster positive working environments, particularly for LGBQ+ people who may be more marginalized within organisations.

Comparative associations of problematic alcohol and cannabis use with suicidal behavior in U.S. military veterans: A population-based study

Alcohol use disorder (AUD) and cannabis use disorder (CUD) are each associated with increased suicidal behavior, but it is unclear how their comorbidity relates to suicide risk. Understanding these associations in U.S. military veterans is especially important, given their heightened risk for suicide, high prevalence of AUD, and increasing access to cannabis. We compared associations of probable AUD, CUD, and AUD/CUD with suicide ideation, plan(s), and attempt(s) in a nationally representative sample of 4,069 veterans surveyed in 2019–2020 as part of the National Health and Resilience in Veterans Study. Among veterans who screened positive for current AUD, 8.7% also screened positive for current CUD. Among veterans who screened positive for current CUD, 33.3% screened positive for current AUD. Current and lifetime positive screens for AUD, CUD, and AUD/CUD were each strongly and independently associated with past-year suicide ideation and lifetime suicide ideation, plan(s), and attempt(s) [odds ratios (ORs) = 1.6–8.7]. Relative to veterans who screened positive for AUD only, veterans who screened positive for AUD/CUD and CUD only had higher odds of past-year suicide ideation (AUD/CUD: OR = 3.3; CUD only: OR = 2.4), lifetime suicide ideation (AUD/CUD: OR = 1.9; CUD only: OR = 2.6) and lifetime suicide plan(s) (AUD/CUD: OR = 1.7; CUD only: OR = 6.1). Collectively, findings suggest that screening positive for CUD might be an especially strong indicator of suicide ideation and planning in veterans with and without AUD, independent of sociodemographic, military, trauma, and other psychiatric factors. These findings underscore the importance of routine screening for CUD in suicide prevention efforts, especially as cannabis becomes more widely available.

Suicidal risk and demoralization in Parkinson disease.

We aimed to determine suicide risk and lifetime suicidal ideation in Parkinson disease (PD) patients versus controls and how depression, demoralization, and insomnia are associated with suicidality. In this case-control study, PD patients and matched controls were recruited from movement disorder clinics, Michael J. Fox Foundation, and Research Match websites. Suicide risk and suicidal ideation were assessed using the Suicidal Behavior Questionnaire-revised (SBQ-R) and Columbia-Suicide Severity Rating Scale. Lifetime depression was assessed using the Brief Lifetime Depression Scale, sleep using Insomnia Severity Index (ISI), demoralization using Diagnostic Criteria for Psychosomatic Research and Kissane Demoralization Scales, and non-motor symptoms using UPDRS Non-Motor Aspects of Experiences of Daily Living scale (nM-EDL). 186 PD participants and 177 controls were matched for age (64.2 ± 7.7years), sex (48.8% female), and socioeconomics. PD participants were not more likely than controls to have high suicide risk (SBQ-R ≥ 7) (7.5% vs. 11.3%; p = 0.22) or to have had a lifetime suicide plan or attempt (2.7% vs. 5.1%; p = 0.24), but were less likely to have had lifetime suicidal ideation (23.1% vs. 35.0%; p = 0.01). PD participants were more likely than controls to have lifetime depression history (34.4% vs. 20.9%; p = 0.004), and demoralization (19.9% vs. 10.7%; p = 0.02), and had higher ISI scores (8.7 ± 5.8 vs. 5.1 ± 4.5; p < 0.0001). PD patients with high versus normal suicide risk had higher nM-EDL scores (16.5 ± 6.8 vs. 10.7 ± 5.9; p = 0.002), and more demoralization (71.4% vs. 21.5%; p < 0.0001). Suicide risk is not elevated and suicidal ideation is uncommon in PD, despite the high prevalence of depression and demoralization.

Factors Associated with Suicidality Among a National Sample of Transgender Veterans.

Correlates of past-year suicidal ideation and lifetime suicide risk among a national sample of transgender veterans were examined. An online, convenience sample of 212 U.S. transgender veterans participated in a cross-sectional survey in February-May 2014. We evaluated associations between sociodemographic characteristics, stigma, mental health, and psychosocial resources with past-year suicidal ideation and lifetime suicide plans and attempts. Participants reported high rates of past-year suicidal ideation (57%) as well as history of suicide plan or attempt (66%). Transgender-related felt stigma during military service and current posttraumatic stress disorder and depressive symptoms were associated with suicide outcomes as were economic and demographic factors.

The impact of a depression awareness campaign on mental health literacy and mental morbidity among gay men

BackgroundHigh prevalences of depression and suicidality have been found among gay men. This paper assesses the possible impact of Blues-out, a depression awareness campaign based on the European Alliance Against Depression targeting the gay/lesbian community in Geneva, Switzerland. MethodsIn 2007 and 2011, pre- and post-intervention surveys were conducted among two distinct samples of gay men in Geneva, recruited by probability-based time–space sampling. Effect sizes and net percent changes are reported for mental health literacy and mental health outcomes in 2007 and 2011 as well as among men aware and unaware of Blues-out in 2011. Results43% of the respondents correctly recognized depression in 2011 with no change vis-à-vis 2007. Despite small effect sizes, significant net decreases (from −18% to −28%) were seen in lifetime suicide plans, 12-month suicidal ideation, lifetime depression, and 4-week psychological distress between 2007 and 2011. These decreases were not accompanied by changes in any of the numerous items on attitudes/knowledge, found only when comparing men aware and unaware of Blues-out in 2011. More men aware of Blues-out found specialists and psychological therapies helpful than their counterparts and correctly identified depression and gay men's greater risk for depression. LimitationsCommunity-level assessment with no control. ConclusionsAlthough improvement in depression recognition and decrease in suicide attempts could not be replicated unequivocally in this adapted intervention among gay men, there are indications that this evidence-based depression awareness campaign may have lessened suicidality and mental morbidity and improved mental health literacy and help-seeking.

Suicidal Thinking Among Adolescents With a History of Attempted Suicide

To examine the risk of suicidal plans and ideation, depression, and other factors (low self-esteem, loneliness, fatalism, pessimism) among adolescents with a lifetime history of attempted suicide. A self-administered questionnaire was used in a school-based survey of five middle schools (grades 6 through 8) enrolling 6,400 students. Usable questionnaires were obtained from 5,423 (85.3%). Data were obtained on a wide range of constructs including recent and lifetime suicide attempts, recent and lifetime suicide plans, recent ideation, symptoms of DSM-IV major depression, self-esteem, pessimism, loneliness, and fatalism. Data on crude prevalence showed thoughts about death, wishing to be dead, thoughts of suicide, and suicide plans were all significantly higher among youths with a history of attempts. Suicidal thinking was related to being more lonely, more fatalistic, and more pessimistic, and to less self-esteem, in addition to depression and a history of attempts. Multivariate analyses revealed the strongest factors associated with current suicidal thinking were history of attempts (odds ratio [OR] = 3.50), depression (OR = 5.34), and recent life stress (OR = 2.64). Compared with youths with none of the factors examined, those with six or more were at extreme risk (OR = 67.87). The strong association between history of suicide attempts, current ideation, and depression indicates that past suicide attempts occur in the context of other signs of psychosocial dysfunction. Given the paucity of epidemiological data on the natural history of suicidal behaviors among youths, more epidemiological studies of the antecedents and consequences of the range of suicidal behaviors among children and adolescents are needed. Given the high risk of subsequent suicidal behaviors by youths who have attempted but not completed suicide, this constitutes a high-risk population on which future research should focus.