Adult Associations of Childhood Suicidal Thoughts and Behaviors: A Prospective, Longitudinal Analysis

Neurocognitive functioning in community youth with suicidal ideation: gender and pubertal effects

BACKGROUND

Although there are extensive data on clinical psychopathology in youth with suicidal ideation, data are lacking regarding their neurocognitive function.

AIMS

To characterise the cognitive profile of youth with suicidal ideation in a community sample and evaluate gender differences and pubertal status effects.

METHOD

Participants (N = 6151, age 11-21 years, 54.9% females) from the Philadelphia Neurodevelopmental Cohort, a non-help-seeking community sample, underwent detailed clinical evaluation. Cognitive phenotyping included executive functioning, episodic memory, complex reasoning and social cognitive functioning. We compared participants with suicidal ideation (N = 672) and without suicidal ideation (N = 5479). Regression models were employed to evaluate differences in cognitive performance and functional level, with gender and pubertal status as independent variables. Models controlled for lifetime depression or general psychopathology, and for covariates including age and socioeconomic status.

RESULTS

Youth with suicidal ideation showed greater psychopathology, poorer level of function but better overall neurocognitive performance. Greater functional impairment was observed in females with suicidal ideation (suicidal ideation × gender interaction, t = 3.091, P = 0.002). Greater neurocognition was associated with suicidal ideation post-puberty (suicidal ideation × puberty interaction, t = 3.057, P = 0.002). Exploratory analyses of specific neurocognitive domains showed that suicidal ideation-associated cognitive superiority was more prominent in post-pubertal males compared with females (Cohen's d = 0.32 and d = 0.11, respectively) across all cognitive domains.

CONCLUSIONS

Suicidal ideation was associated with poorer functioning yet better cognitive performance, especially in post-pubertal males, as measured by a comprehensive cognitive battery. Findings point to gender and pubertal-status specificity in the relationship between suicidal ideation, cognition and function in youth.

DECLARATION OF INTEREST

R.B. serves on the scientific board and reports stock ownership in 'Taliaz Health', with no conflict of interest relevant to this work. M.A.O. receives royalties for the commercial use of the Columbia-Suicide Severity Rating Scale from the Research Foundation for Mental Hygiene. Her family owns stock in Bristol-Myers Squibb. All other authors declare no potential conflict of interest.

Association of Parental Incarceration With Psychiatric and Functional Outcomes of Young Adults

IMPORTANCE

In 2016, an estimated 8% of US children younger than 18 years had experienced the incarceration of a parent, and rates were substantially higher among children from racial and ethnic minority backgrounds and disadvantaged groups. Little is known about whether parental incarceration during childhood is associated with adult psychiatric problems and functional outcomes.

OBJECTIVE

To examine whether parental incarceration is associated with increased levels of psychiatric diagnosis and poor outcomes in health, legal, financial, and social domains in adulthood.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the community-representative, prospective, longitudinal Great Smoky Mountains Study. Children and their parents were interviewed up to 8 times from January 1993 to December 2000 (ages 9-16 years; 6674 observations of 1420 participants) using the Child and Adolescent Psychiatric Assessment, which assessed parental incarceration, childhood psychiatric diagnoses, and other adversities. Young adults were followed up at ages 19, 21, 25, and 30 years from January 1999 to December 2015 (4556 observations of 1334 participants) to assess psychiatric diagnoses and functional outcomes indicative of a disrupted transition to adulthood. Data analysis was conducted from June 2018 to June 2019.

RESULTS

By age 16 years, 475 participants (weighted percentage, 23.9%) had a parental figure who had been incarcerated, including 259 young men (22.2%) and 216 young women (25.5%). Parental incarceration was associated with higher prevalence of childhood psychiatric diagnoses (eg, any depressive diagnosis: adjusted odds ratio [aOR], 2.5; 95% CI, 1.3-4.6; P = .006; attention-deficit/hyperactivity disorder: aOR, 2.3; 95% CI, 1.0-5.5; P = .06; and conduct disorder: aOR, 2.5; 95% CI, 1.4-4.3; P = .001). After accounting for childhood psychiatric diagnoses and adversity exposure, parental incarceration remained associated with increased odds of having an adult anxiety disorder (aOR, 1.7; 95% CI, 1.0-3.0; P = .04), having an illicit drug use disorder (aOR, 6.6; 95% CI, 2.6-17.0; P < .001), having a felony charge (aOR, 3.4; 95% CI, 1.8-6.5; P < .001), incarceration (aOR, 2.8; 95% CI, 1.4-5.4; P = .003), not completing high school (aOR, 4.4; 95% CI, 2.2-8.8; P < .001), early parenthood (aOR, 1.7; 95% CI, 1.0-3.0; P = .04), and being socially isolated (aOR, 2.2; 95% CI, 1.2-4.0; P = .009).

CONCLUSIONS AND RELEVANCE

This study suggests that parental incarceration is associated with a broad range of psychiatric, legal, financial, and social outcomes during young adulthood. Parental incarceration is a common experience that may perpetuate disadvantage from generation to generation.

Trajectories of Suicidal Ideation from Middle Childhood to Early Adolescence: Risk and Protective Factors

Suicidal ideation is considered to be the first step on the pathway to suicide. Despite the fact that suicidal ideation is surprisingly prevalent among preadolescent children in China and elsewhere, and despite its possible increase during the transition into adolescence, its developmental patterns and predictors during this period are unclear, thus precluding a meaningful understanding of its determinants and possible trajectories. Thus, this study aimed to identify suicidal ideation trajectories and multisystemic predictors covering the transition from middle childhood to early adolescence. A total of 715 Chinese elementary school students (M_age = 8.95, SD = 0.71; 54.5% was male) participated in assessments at six time points, using six-month assessment intervals. Growth mixture modeling analyses extracted three distinct trajectories of suicidal ideation: "low-stable" (86.4%), "moderate-increasing" (7.1%) and "high-start" (6.5%). Multivariate logistic regression analyses revealed that social anxiety and academic anxiety served as risk factors for the adverse developmental trajectories of suicidal ideation; whereas self-esteem, life satisfaction, and academic achievement served as protective factors for the positive developmental trajectory of suicidal ideation. The identification of three subgroups with unique predictors highlights the importance of individual difference considerations in understanding the progression of suicidal ideation in childhood and adolescence and the need for specific programs tailored to the unique characteristics of the relevant trajectories. Furthermore, given that suicidal ideation may start in a proportion of middle childhood youths and continue into adolescence, the middle childhood period should provide an important window of opportunity for large-scale screening and prevention of the escalation of suicidality in adolescence.

Evidence Base Update of Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth

The current review provides an evidence base update of psychosocial treatments for self-injurious thoughts and behaviors (SITBs) in youth. A systematic search was conducted of 2 major scientific databases (PsycInfo and PubMed) and ClinicalTrials.gov for relevant randomized controlled trials (RCTs) published prior to June 2018. The search identified 26 RCTs examining interventions for SITBs in youth: 17 were included in the 2015 review and 9 trials were new to this update. The biggest change since the prior review was the evaluation of Dialectical Behavior Therapy for adolescents (DBT-A) as the first Level 1: Well-established intervention for reducing deliberate self-harm (composite of nonsuicidal and suicidal self-injury) and suicide ideation in youth and Level 2: Probably efficacious for reducing nonsuicidal self-injury and suicide attempts. Five other interventions were rated as Level 2: Probably efficacious for reducing SITBs in youth, with the new addition of Integrated Family Therapy. This evidence base update indicates that there are a few promising treatments for reducing SITBs in youth. Efficacious interventions typically include a significant family or parent training component as well as skills training (e.g., emotion regulation skills). Aside from DBT-A, few treatments have been examined in more than one RCT. Given that replication by independent research groups is needed to evaluate an intervention as Well-established, future research should focus on replicating the five promising interventions currently evaluated as Probably efficacious. In addition, an important future direction is to develop brief efficacious interventions that may be scalable to reach large numbers of youth.

Autonomic correlates of lifetime suicidal thoughts and behaviors among adolescents with a history of depression

Suicidal thoughts and behaviors (STBs) have been associated with emotion dysregulation and atypical responses to affective and stressful stimuli. To investigate the psychophysiology involved, we measured changes in respiratory sinus arrhythmia (RSA) and cardiac pre-ejection period (PEP; indexing parasympathetic and sympathetic functioning, respectively) in response to stressful- and sadness-eliciting laboratory probes. Our sample included adolescents with a history of depression and STBs (n = 177), adolescents with a history of depression but no history of STBs (n = 47), and healthy controls (n = 175). The outcome of interest was the most severe form of clinician-rated STBs across the subject's lifetime. In partial support of our hypotheses, during the stressful task, adolescents with a history of depression and STBs did not evidence the RSA decrease that was exhibited by controls and displayed greater PEP shortening compared to ever-depressed adolescents with no lifetime STBs. No group differences were found in either RSA or PEP reactivity to the sadness-eliciting stimulus. As expected, severity of STBs was positively correlated with the extent of PEP shortening during the stressful task. The results suggest that adolescents with a history of depression and STBs experience blunted parasympathetic responses to stress along with compensatory efforts. Our findings contribute to a better understanding of STBs among youths and underscore that future studies should examine physiological risk factors for these psychopathological outcomes.

Associations between self-harm and chronic disease among adolescents: Cohort study using statewide emergency department data

INTRODUCTION

We sought to understand the association between youthful self-harm and subsequent chronic disease-related healthcare utilization and whether self-harm reflects unique vulnerability in comparison with severe psychiatric disorders.

METHODS

We used a retrospective matched cohort design with statewide, all-payer, individually linked emergency department (ED) data from California, USA. Risk of future ED visits for common chronic conditions in adolescence (headaches, asthma, epilepsy, diabetes, and gastrointestinal disorders, assessed using ICD-9 diagnoses) were compared between three adolescent study groups presenting to an ED in 2010: self-harm patients (n = 5,484), patients with psychiatric complaints but no self-harm (n = 14,235), and patients with other complaints (n = 16,452). Cohort follow-up ended on Sept. 30, 2015. Analyses were adjusted for patients' prior histories of ED utilization for chronic conditions as well as patient- and area-level sociodemographic characteristics.

RESULTS

Risk of subsequent ED visits was higher among self-harm patients compared to non-psychiatric control patients for subsequent epilepsy- (aRR = 1.77, 95% CI [1.42, 2.21]). Risk of subsequent ED visits was higher among psychiatric patients compared to non-psychiatric control patients for subsequent headache- (aRR = 1.31, 95% CI [1.21, 1.42]), and epilepsy-related problems (aRR = 1.85, 95% CI [1.55, 2.21]). Self-harm patients were at higher risk than psychiatric patients for subsequent gastrointestinal disorder (aRR = 1.76, 95% CI [1.03, 3.01]).

CONCLUSIONS

Findings suggest that self-harm behavior and psychiatric disorders are associated with increased ED utilization for subsequent chronic disease-related ED utilization. Chronic disease among adolescent psychiatric patients should be attended to, potentially involving new models of clinical follow-up care.

Preliminary evidence of an association between increased cortical inhibition and reduced suicidal ideation in adolescents treated for major depression

BACKGROUND

Suicide is a leading cause of death among youth. Prior research using transcranial magnetic stimulation (TMS) has implicated deficits in GABAergic cortical inhibition in adolescent suicidal behavior, yet no studies have assessed whether cortical inhibition varies over time in conjunction with changes in suicidal ideation (SI). This study examined dynamic changes in long-interval intracortical inhibition (LICI), a TMS measure of GABA_B-mediated inhibition, and their relationship with changes in SI in a small sample of adolescents undergoing pharmacologic treatment for depression.

METHODS

Ten depressed adolescents (aged 13-17) underwent clinical assessment and TMS testing at baseline and again at follow-up. All were treated with antidepressant medication in the interim. SI was measured with the Columbia Suicide Severity Rating Scale (C-SSRS) Intensity of Ideation subscale. LICI was measured at interstimulus intervals of 100 and 150 ms.

RESULTS

There was a significant partial correlation, controlling for change in depression severity, between ΔLICI-100 and change in SI as measured by ΔC-SSRS (ρ = .746, df = 7, p = .021), which remained after also controlling for time to follow-up assessment (ρ = .752, df = 6, p = .032). No significant correlation was observed between ΔLICI-150 and change in SI.

LIMITATIONS

Sample size; variable follow-up interval; inability to control for age, sex, and potential treatment effects.

CONCLUSIONS

These data offer preliminary signal of an association between increases in GABA_B-mediated cortical inhibition and reduction in SI over time in adolescents treated for depression. Further studies are warranted to explore the role of cortical inhibition in adolescent suicidal ideation and behavior.

Implicit Identification with Death Predicts Suicidal Thoughts and Behaviors in Adolescents

Prior research indicates that adults' implicit identification with death can be used to predict suicidal thoughts and behaviors (STBs) in the community. However, no studies have examined whether this effect is found among adolescents-a group for whom suicide is the 2nd leading cause of death. The current study tested the utility of implicit identification with death, using a Death Implicit Association Test (IAT), for detecting and predicting STBs in adolescents. Participants were 141 adolescents 12-19 years of age (81.6% female, 74.5% White) with a current psychiatric disorder and/or currently receiving outpatient psychiatric treatment. All participants completed the Death IAT and self-report measures of STBs at baseline, as well as self-report measures of STBs at 6-month and 1-year follow-ups. At baseline, stronger implicit identification with death (higher Death IAT score) was related to greater suicide ideation (SI) frequency, severity, and duration, but did not differ based on suicide attempt history. Prospectively, higher Death IAT scores predicted any occurrence (but not frequency) of SI over the subsequent year, but not when controlling for prior SI. Death IAT scores were higher among adolescents with prior attempts who reattempted suicide over the follow-up. Examination of stimuli-level results suggested that Death IAT differences may be driven by responses on trials with specific words, including suicide and die. Implicit identification with death may be a useful behavioral indicator of suicide risk in adolescents. Preliminary findings suggest that the Death IAT may aid in predicting STBs among youth receiving outpatient treatment.

High-frequency repetitive TMS for suicidal ideation in adolescents with depression

BACKGROUND

This exploratory study sought to examine the effect of an acute course of high-frequency repetitive TMS on suicidal ideation in adolescents.

METHODS

Data were pooled from 3 prior protocols providing a 30-session course of open-label TMS treatment for adolescents with treatment-resistant depression. All participants (n = 19) were outpatients taking antidepressant medication, with TMS provided as adjunctive treatment. Suicidality was assessed at baseline, after 10 treatments, after 20 treatments, and after 30 treatments. Outcome measures of suicidal ideation included the Columbia Suicide Severity Rating Scale (C-SSRS) "Intensity of Ideation" subscale and Item 13 "Suicidality" on the Children's Depression Rating Scale, Revised (CDRS-R).

RESULTS

The predicted odds of suicidal ideation (CDRS-R Item 13 and C-SSRS Intensity of Ideation subscale) significantly decreased over 6 weeks of acute TMS treatment without adjustments for illness (depression) severity. However, the magnitude of the decrease in the predicted odds of suicidal ideation across 6 weeks of treatment was attenuated and rendered non-significant in subsequent analyses that adjusted for illness (depression) severity.

LIMITATIONS

This was an exploratory study with a small sample size and no sham control. Regulatory and ethical barriers constrained enrollment of adolescents with severe suicidality.

CONCLUSIONS

The present findings suggest that open-label TMS mitigated suicidal ideation in adolescents through the treatment and improvement of depressive symptom severity. Although caution is warranted in the interpretation of these results, the findings can inform the design and execution of future interventional trials targeting suicidal ideation in adolescents.

Development and Validation of the Therapist Barriers to Engaging Parents (TBEP) Measure

Parent engagement is a well-documented challenge when delivering child and adolescent mental health treatments. Therapists' internal experiences, and how they respond to parents, may create a barrier to the parent engagement process. The current study developed the 13-item Therapist Barriers to Engaging Parents measure (TBEP) to assess providers' internal and external experiences that operate as barriers to parent engagement. The TBEP was completed by 148 child and family therapists across the United States. The TBEP demonstrated strong internal reliability (Cronbach α = .86), and was negatively correlated with counselor efficacy, and significantly positively correlated with burnout, indicating convergent validity. Incremental validity of the subscales of the TBEP was also demonstrated. The TBEP appears to be a psychometrically sound measure of the internal barriers mental health providers experience when trying to engage parents.

Cortical inhibitory markers of lifetime suicidal behavior in depressed adolescents

Although suicide is the second-leading cause of death in adolescents and young adults worldwide, little progress has been made in developing reliable biological markers of suicide risk and suicidal behavior. Converging evidence suggests that excitatory and inhibitory cortical processes mediated by the neurotransmitters glutamate and γ-aminobutyric acid (GABA) are dysregulated in suicidal individuals. This study utilized single- and paired-pulse transcranial magnetic stimulation (TMS) to assess excitatory and inhibitory cortical functioning in healthy control adolescents (n = 20), depressed adolescents without any history of suicidal behavior ("Depressed", n = 37), and depressed adolescents with lifetime history of suicidal behavior ("Depressed+SB", n = 17). In a fixed-effects general linear model analysis, with age, sex, and depression severity as covariates, no significant group main effects emerged for resting motor threshold, intracortical facilitation, short-interval intracortical inhibition, or cortical silent period. However, group main effects were significant for long-interval intracortical inhibition (LICI) at interstimulus intervals (ISIs) of 100 ms and 150 ms, but not 200 ms. Depressed+SB adolescents demonstrated impaired LICI compared to healthy control and Depressed adolescents, while healthy control and Depressed participants did not differ in LICI. Multiple linear robust regression revealed significant positive linear relationships between lifetime suicidal behavior severity and impairment in LICI at 100-ms and 150-ms ISIs. In a post hoc receiver operating characteristic analysis, LICI significantly discriminated Depressed from Depressed+SB youth in 100-ms and 150-ms paradigms. These findings suggest that GABAB receptor-mediated inhibition is distinctly dysregulated in depressed adolescents with histories of suicidal behavior. Further research is warranted to establish the utility of cortical inhibition in the assessment of suicide risk and as a target for treatment interventions.

Suicidal ideation in adult ADHD: Gender difference with a specific psychopathological profile

OBJECTIVE

To investigate suicidal ideation (SI) in patients with adult ADHD (aADHD), and its association with gender and psychopathology.

METHODS

Case-control study with 206 participants (patients = 103/healthy controls = 103; matched on gender, age, and education). SI was assessed by the Beck-I Depression-Inventory. The Conners' Adult ADHD Rating Scale (CAARS) was used to characterize the ADHD symptom-domains.

RESULTS

Compared to controls, the likelihood of SI was significantly higher in females with ADHD (odds ratio[OR] = 25.0 (95%CI:2.98-200.0); the difference was not significant in males (OR = 2.09 (95%CI:0.75-5.81). In females, "Problems with Self-Concept" scores on the CAARS showed the closest association with SI (OR = 5.60,95%CI:2.34-13.41]), while in males it was "Impulsivity" scores (OR = 3.01,95%CI:1.50-6.06).

CONCLUSION

Our findings extend previously described transdiagnostic associations of specific psychopathological risk factors to aADHD, including problems with self-concept and impulsivity, which are robustly associated with suicidality across diagnostic boundaries. In addition, they indicate that these associations exhibit pronounced gender-specificity in aADHD.