Suicidal behaviours among adolescents from 90 countries: a pooled analysis of the global school-based student health survey

Suicidal ideation and behavior in youth in low- and middle-income countries: A brief review of risk factors and implications for prevention

Although global rates of suicide have dropped in the last 30 years, youth in low- and middle-income countries (LMICs) continue to be highly represented in suicide statistics yet underrepresented in research. In this review we present the epidemiology of suicide, suicidal ideation, and suicide attempts among youth in LMICs. We also describe population-level (attitudes toward suicide, socioeconomic, and societal factors) and individual-level clinical and psychosocial risk factors, highlighting specific considerations pertaining to youth in LMICs. These specific considerations in risk factors within this population can inform how multi-level prevention strategies may be targeted to meet their specific needs. Prevention and intervention strategies relying on the stepped-care framework focusing on population-, community-, and individual level targets while considering locally- and culturally relevant practices are key in LMICs. In addition, systemic approaches favoring school-based and family-based interventions are important among youth. Cross-culturally adapted multimodal prevention strategies targeting the heterogeneity that exists in healthcare systems, suicide rates, and risk factors in these countries should be accorded a high priority to reduce the burden of suicide among youth in LMICs.

Relationship Between the Early Initiation of Substance Use and Attempted Suicide Among in-School Adolescents in Seven Low- or Middle-Income African Countries: An Analysis of the Global School-Based Student Health Survey Data

Background: Preventing suicide among adolescents is an urgent global public-health challenge, especially in Africa. Accordingly, the aim of this study was to examine the relationship between the early initiation (< 12 years old) of substance use (cigarette smoking, alcohol use, and drug use) and attempted suicide among in-school adolescents in seven African countries.

Methods: Data on the early initiation of substance use and on attempted suicide among in-school adolescents over the previous 12 months in Benin, Liberia, Mauritius, Mozambique, Namibia, Seychelles, and the United Republic of Tanzania were collected from Global School-based Student Health Surveys and were pooled to determine the overall prevalence of these behaviors in adolescents. Univariate and multivariate logistic regressions were then performed to evaluate country-specific associations between the early initiation of substance use and attempted suicide in these adolescents, followed by meta-analyses to evaluate overall pooled associations.

Results: In the abovementioned seven African low- or middle-income countries (LMICs), overall weighted prevalences of attempted suicide and early initiation of cigarette smoking, alcohol use, and drug use among in-school adolescents were 16.05, 7.76, 17.68, and 3.48%, respectively. Multivariate logistic regression analyses revealed that relative to non-smoking, the early initiation of smoking was significantly associated with attempted suicide in these adolescents [OR (95% CI) = 1.783 (1.219–2.348)]. Additionally, the relationship between early initiation of cigarette smoking and attempted suicide is mostly driven by a higher association in girls [OR (95% CI) = 1.867 (1.031–2.703)] than boys [OR (95% CI) = 1.392 (0.995−1.789)]. Moreover, relative to not using other drugs, the early and later initiation of other drug use were also significantly associated with attempted suicide in these adolescents [ORs (95% CIs) = 2.455 (1.701–3.208) and 1.548 (1.198–1.898)].

Conclusion: Programs that can eliminate or decrease the early initiation of substance use among adolescents should be implemented in African LMICs to prevent subsequent suicide attempts, especially among adolescent girls.

Epidemiology of suicidal behaviours amongst school-going adolescents in post-conflict Sierra Leone

BACKGROUND

Children and young people living in post-conflict contexts are at an increased risk of suicidal behaviours (ideations and attempts). Not much is known about the extent of suicidal behaviours amongst adolescents in most notable post-conflict countries in sub-Saharan Africa, including Sierra Leone.

METHODS

We performed a secondary analysis of data from the 2017 Sierra Leone World Health Organisation Global School-based Student Health Survey conducted amongst students in secondary schools nationwide. We estimated the 12-month prevalence and performed bivariable and multivariable analyses to assess the correlates of suicidal behaviours.

RESULTS

Of the 2,798 analytic sample, 14.6% (males = 15.1%, females = 14.0%) reported suicidal ideation, and the 12-month prevalence estimate of suicide attempt was 19.6% (male = 20.9%, females =17.8%). The factors associated with suicidal behaviours were multi-layered. While no statistically significant gender association with suicide ideation or attempt was observed at the personal level, being aged 18 or older, loneliness, and health risk behaviours (cannabis use, and leisure time sedentary behaviour) were associated with increased odds of suicidal behaviours. Within the family context, parental monitoring was associated with increased odds of suicidal ideation, but parental supervision was associated with reduced odds of suicide ideation.

LIMITATIONS

The cross-sectional nature of the data did not support causal inferences.

CONCLUSIONS

Taken together, professional mental healthcare would be helpful in treating adolescent emotional problems (e.g., depression and loneliness) related to suicidal behaviours; but prevention and intervention programmes targeted at addressing adolescent health risk behaviours, and familial and interpersonal problems may yield more favourable outcomes.

Characteristics of interpersonal conflicts preceding youth suicide: analysis of data from the 2017 National Violent Death Reporting System

BACKGROUND

Deaths by suicide among US adolescents aged 10 to 19 increased by more than 85% between 2007 and 2017. Interpersonal conflicts with peers or family members, in combination with biological, psychological, and cognitive attributes of adolescents, are among risk factors. More insight about contextual factors, including timing of conflicts relative to suicide, would be useful for professionals and programmers.

METHOD

We used data from the 2017 National Violent Death Reporting System (NVDRS) reflecting most cases in 37 US states to explore contextual circumstances in adolescent death by suicide preceded by interpersonal conflicts. We calculated descriptive statistics and conducted content analysis of narratives to identify attributes of 197 cases.

RESULTS

Most deaths by suicide (n = 155) occurred within 24 hr of the conflict; most conflicts involved the adolescent and family members (n = 138). When subject matter was described, most conflicts (n = 27) focused on concerns with an adolescent's behavior. Nearly a quarter of cases (n = 49) involved technology, including technology restrictions as punishment, as either a primary or additional aspect of the conflict.

CONCLUSIONS

Our findings provide support for prior research suggesting links between technology and mental health concerns, including suicidality, among adolescents. While previous works have identified both positive and negative aspects of the use of technology by adolescents, our findings suggest that restriction of technology as a punishment may be an additional contextual factor of interest in a proportion of youth suicides preceded by an argument. Given ongoing regular use of technology, practitioners should address these potential risk factors regardless of risk status.

Association of parenting with suicidal ideation and attempts in children and youth: protocol for a systematic review and meta-analysis of observational studies

BACKGROUND

Suicide is a leading cause of death in children and youth, with suicidal thoughts and suicide attempts (referred to as non-fatal suicidal behaviors (NFSB)) being among its strongest predictors. Positive parenting (e.g., warmth, responsiveness), negative parenting (e.g., control, hostility), and parent-child relationship quality (e.g., trust, communication) have been reported to be associated with differences in NFSB in this population. To date, no comprehensive systematic review has considered together the wide range of parenting factors studied in relation to NFSB, and no meta-analysis of existing findings has been conducted. The present study will critically appraise and synthesize the existing evidence from observational studies that examine the relationships between parenting factors and (i) suicidal ideation and (ii) suicide attempt in children and youth.

METHODS

Studies will be retrieved from APA PsycInfo, MEDLINE, CINAHL, Embase, Scopus, and the Cochrane Library databases. Retrospective, cross-sectional, and longitudinal studies, conducted in clinical and population settings, among youth aged less than 25 years and published as articles and dissertations in English or French will be eligible. Two reviewers will select articles using the Covidence Software after title and abstract screening and full-text assessment, will extract information using double data entry, and will appraise studies' quality using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Any disagreements will be discussed with a third reviewer. Publication bias will be evaluated using funnel plots and Egger's test. In addition to a narrative summary of results, meta-analyses will be conducted using results from at least three studies. Three-level random effect models will allow to derive pooled estimates from dependent effect sizes (from the same sample or study). In case of significant heterogeneity, moderation analyses will be performed considering participants' characteristics and methodological aspects of studies. The results will be reported according to the PRISMA guidelines, and the certainty of evidence will be assessed using the GRADE approach.

DISCUSSION

In highlighting parenting factors associated with NFSB and in estimating the overall strength of these associations in children and youth, our results will inform further intervention and prevention strategies designed for young people experiencing NFSB and their families.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020165345.

Pathways linking bullying victimisation and suicidal behaviours among adolescents

AIMS

To examine the pathways explaining the association between bullying victimisation and suicidal behaviours among school-based adolescents.

METHODS

We used data from the Global School-based Student Health Survey from 90 countries conducted between 2003 and 2017. We applied multivariate regression and generalised structural equation models to examine the pathways.

RESULTS

Of 280,076 study adolescents, 32.4% experienced bullying and 12.1%, 11.1% and 10.9% reported suicidal ideation, suicidal planning and suicidal attempt, respectively. Adolescents who experienced bullying had higher rates of hunger (8.7% vs 5.0%), drinking soft drinks (44.0% vs 40.2%), truancy (35.8% vs 22.7%), smoking (14.0% vs 6.9%), alcohol consumption (19.9% vs 11.8%), peer victimisation (54.0% vs 25.6%), peer conflict (47.4% vs 20.1%), sleep disturbance (13.7% vs 5.6%), loneliness (18.1% vs 7.6%), no close friends (7.5% vs 5.2%), lack of peer support (64.9% vs 53.3%), lack of parental connectedness (67.0% vs 60.4%) and less parental bonding (64.1% vs 55.2%). Nearly one-fourth (18.7%) of the total association between bullying and suicidal ideation was mediated by loneliness. Similarly, sleep disturbances and alcohol consumption also mediated 4 to 9% of the association between bullying and suicidal behaviours.

CONCLUSION

This study suggests targeted policies and early implementation of interventional strategies focusing on addressing loneliness, sleep disturbance and alcohol consumption to reduce the risk of adverse suicidal behaviours among adolescents.

The men's mental health perspective on adolescent suicide in the COVID-19 era

OBJECTIVE

The COVID-19 pandemic has drastically changed society and introduced many new factors to consider in adolescent suicide risk assessment and prevention. One complexity that warrants consideration is the male-specific impacts of the pandemic within adolescence.

METHODS

A review of the relevant literature.

RESULTS

Matters of social distancing, virtual education, and substance use may impact adolescent men in fashions that raise their suicide risk more significantly relative to adolescent women. Social distancing may impact adolescents' friendships and generate a regression back to the nuclear family; qualities of male adolescents' friendships and of masculinity suggest that these impacts may be more severe in adolescent men and may directly raise suicide risk. Virtual schooling yields educational and social setbacks; losses of team sports, male mentors, and the implications of diminished educational advancement may more adversely affect adolescent men and raise risk. Substance use has increased in the pandemic, particularly amongst adolescent men. There are direct associations with suicide risk as well as indirectly through increased parental conflict and punishment.

CONCLUSION

As adolescent men die by suicide at significantly elevated rates relative to adolescent women, a male-specific consideration of these impacts is indicated to address adolescent suicide in our current era. Recommendations are made for integrating these considerations into updated adolescent suicide risk assessment and prevention efforts.

Neuroimaging Studies of Nonsuicidal Self-Injury in Youth: A Systematic Review

Nonsuicidal self-injury (NSSI) is prevalent and affects mainly the youth population. It is prospectively associated with suicide attempts, making it a target for suicide prevention. Recently, several studies have investigated neural pathways of NSSI using neuroimaging. However, there is a lack of systematized appraisal of these findings. This systematic review aims to identify and summarize the main neuroimaging findings of NSSI in youth. We followed PRISMA statement guidelines and searched MEDLINE, APA PsycInfo, and Google Scholar databases for neuroimaging studies, irrespective of imaging modality, specifically investigating NSSI in samples with a mean age of up to 25 years old. Quality assessment was made using the Newcastle–Ottawa and Joanna Briggs Institute scales. The initial search retrieved 3030 articles; 21 met inclusion criteria, with a total of 938 subjects. Eighteen studies employed functional neuroimaging techniques such as resting-state and task-based fMRI (emotional, interpersonal exposure/social exclusion, pain, reward, and cognitive processing paradigms). Three studies reported on structural MRI. An association of NSSI behavior and altered emotional processing in cortico-limbic neurocircuitry was commonly reported. Additionally, alterations in potential circuits involving pain, reward, interpersonal, self-processing, and executive function control processes were identified. NSSI has complex and diverse neural underpinnings. Future longitudinal studies are needed to understand its developmental aspects better.

Prospective Associations of Frequent Pain Symptoms With Suicidal Behavior in Adolescents

Chronic pain and suicidal behavior are prevalent in adolescents. This longitudinal study examined the associations between pain symptoms and suicidal behavior in adolescents. A total of 7,072 adolescents participated in a follow-up study of behavior and health in Shandong, China. A self-administered structured questionnaire was used to assess pain symptoms (headache, stomachache, and other nonspecific pain), insomnia, anxiety/depression, substance use, stressful life events, prior suicidal behavior, and family environment in November-December in 2015. One year later, a follow-up survey was conducted. Mean age of the sample was 14.6 years, and half were female. Of the sample, 44.8% and 8.4% reported having one or more pain symptoms "sometimes" and "often", respectively. A total of 22.4% and 10.6% reported having lifetime suicidal behavior at baseline and subsequent suicidal behavior over the 1-year follow-up, respectively. Frequent pain was significantly associated with increased risk of suicidal behavior at baseline (OR=1.64, 95%CI=1.32-2.03) and during the subsequent year (OR=1.50, 95%CI=1.17-1.93) while adjusting for adolescent individual and family covariates. Among adolescents without a history of prior suicidal behavior, frequent pain was significantly associated with an approximately 70% increased risk of incident suicidal behavior (OR= 1.69, 95%CI=1.14-2.51). In conclusion, frequent pain appears to be predictive of adolescent suicidal behavior one year later. PERSPECTIVE: This article presents the prospective associations of frequent pain symptoms with suicidal behavior in adolescents. Frequent pain was associated with a 50-70% increased risk of suicidal behavior 1 year later. The finding underscores the importance of pain assessment and treatment in comprehensive suicide prevention efforts in adolescents.

Comparative Analysis of Lifetime Suicide Attempts among Mexican Adolescents, over the Past 12 Years

OBJECTIVE

To compare the occurrence of suicide attempts across nationally representative samples of the Mexican adolescent population over the past 12 years, and to analyze its association with sociodemographic, lifestyle and mental-health indicators.

METHODOLOGY

Data were drawn from the 2006, 2012 and 2018 National Health and Nutrition Surveys (n = 25,056; 21,509; and 17,925 adolescents, respectively). Estimates were based on standardized measurements.

RESULTS

The estimated lifetime prevalence rates of suicide attempts were 1.1% in 2006, 2.7% in 2012, and 3.9% in 2018, indicating a 3.4-fold increase. Across the three survey periods, women yielded rates nearly three times higher than men. Lifetime prevalence grew the most among adolescents aged 13-15 years. Compared to the other respondents, the odds of lifetime suicide attempts proved seven times as high for those who had been sexually abused during their childhood, five times as high for those who had been diagnosed with a depressive disorder, three times as high for those who had suffered physical aggression and twice as high for those who had smoked 100+ cigarettes in their lifetimes and those who consumed alcohol.

CONCLUSION

The sharp increase in suicide attempts in Mexico calls for an urgent public-health response via universal and targeted interventions supported by national policy and sustained federal funding.

Psychosocial Factors Associated with Suicidal Ideation Among HIV/AIDS Patients on Follow-Up at Dessie Referral Hospital, Northeast Ethiopia: A Cross-Sectional Study

Background

Psychosocial and mental health problems are common among HIV/AIDS patients that affect sustained utilization of healthcare services. To date, information is scarce regarding the perceived stigma, level of social support, and suicidal ideation among HIV/AIDS patients in the study setting. Therefore, this study aimed to assess psychosocial factors associated with suicidal ideation among HIV/AIDS patients on follow-up in the study setting.

Methods

A hospital-based cross-sectional study was conducted among people living with HIV/AIDS (PLWH) on antiretroviral therapy follow-up for at least six months at a referral hospital in northeastern Ethiopia from November to January 2019. A total of 395 study participants of antiretroviral therapy clinic visitors were selected systematically. A binary logistic regression model was fitted to identify factors associated with suicidal ideation among PLWH. An adjusted odds ratio (AOR) with 95% confidence interval (CI) and variables having less than or equal 0.05 p-value used to declare statistical significant association.

Results

This study revealed that 45.3%, 56.5%, and 20%, had perceived stigma, poor social support, and depression, respectively. Moreover, the prevalence of suicidal ideation was 9.4% (95% CI: 6.7 to 12.7) of which, 3.3% had attempted to kill themselves. Low body mass index (AOR=4.11, 95% CI: 1.70 9.91), stages three and above illnesses (AOR=6.63, 95% CI: 1.30 33.79), depression (AOR=4.67, 95% CI: 4.67, 95% CI: 1.75 3.93), poor social support (AOR=4.18, 95% CI: 1.46 11.94), and fair and poor adherence (AOR=3.51, 95% CI: 1.14 10.85) were factors associated with suicidal ideation among PLWH.

Conclusion

This study showed that mental disorders and psychosocial problems were common among PLWH. The poor social support, depression, low body mass index, and poor adherence to ART medications were factors associated with suicidal ideation. This finding underscores the importance of regular screening for common mental health disorders and the strengthening of counseling services, nutritional, and psychosocial support programs.

Suicidal behaviours among deaf adolescents in Ghana: a cross-sectional study

Background

A growing global concern is that suicide research has paid little attention to young people with disabilities, particularly, in low- and middle-income countries (LAMICs). We aimed to estimate the 12-month prevalence of suicidal ideation and attempt and describe some associations among deaf adolescents in Ghana.

Methods

This is a cross-sectional anonymous self-report survey involving a nationally representative random sample of 450 school-going deaf adolescents. Data analysis included bivariate and multivariable approaches.

Results

The overall 12-month prevalence of suicidal ideation was 19·3% (95% confidence interval [CI] = 15·8–23·3) and suicidal attempt was 15·6% (95% CI = 12·3–19·2). Although alcohol use and parental divorce were strongly associated with increased odds of both suicidal ideation and attempt, high subjective mental well-being was associated with reduced odds of both suicidal ideation and attempt. Living with no parents and being a final year student were associated with suicidal ideation, while male gender was associated with suicidal attempt.

Conclusions

The prevalence of suicidal behaviours among school-going deaf adolescents in this study compares with estimates among in-school non-deaf adolescents in Ghana and other LAMICs in Africa, and also highlights the need for prevention efforts against the onset of suicidal ideation and possible transition to attempt and suicide among deaf adolescents.

Comparative Efficacy and Acceptability of Psychotherapies for Self-harm and Suicidal Behavior Among Children and Adolescents: A Systematic Review and Network Meta-analysis

IMPORTANCE

Self-harm and suicidal behavior are associated with substantial morbidity and mortality among children and adolescents. The comparative performance of psychotherapies for suicidality is unclear because few head-to-head clinical trials have been conducted.

OBJECTIVE

To compare the efficacy of psychotherapies for the treatment of self-harm and suicidality among children and adolescents.

DATA SOURCES

Four major bibliographic databases (PubMed, MEDLINE, PsycINFO, and Embase) were searched for clinical trials comparing psychotherapy with control conditions from inception to September 2020.

STUDY SELECTION

Randomized clinical trials comparing psychotherapies for suicidality and/or self-harm with control conditions among children and adolescents were included after a blinded review by 3 independent reviewers (A.B., M.P., and J.W.).

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed for data abstraction, and the Cochrane risk of bias tool was used to evaluate study-level risk of bias. Data abstraction was performed by 1 reviewer (A.B.) and confirmed by 2 independent blinded reviewers (J.W. and M.P.). Data were analyzed from October 15, 2020, to February 15, 2021.

MAIN OUTCOMES AND MEASURES

The primary outcomes were dichotomized self-harm and retention in treatment. The secondary outcomes were dichotomized all-cause treatment discontinuation and scores on instruments measuring suicidal ideation and depressive symptoms. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary odds ratios (ORs) and Cohen d standardized mean differences (SMDs). Negative Cohen d SMDs or ORs less than 1 indicated that the treatment reduced the parameter of interest relative to the control condition (eg, signifying a beneficial association with suicidal ideation).

RESULTS

The systematic search generated 1272 unique records. Of those, 44 randomized clinical trials (5406 total participants; 4109 female participants [76.0%]) from 49 articles were selected (5 follow-up studies were merged with their primary clinical trials to avoid publication bias). The selected clinical trials spanned January 1, 1995, to December 31, 2020. The median duration of treatment was 3 months (range, 0.25-12.00 months), and the median follow-up period was 12 months (range, 1-36 months). None of the investigated psychotherapies were associated with increases in study withdrawals or improvements in retention in treatment compared with treatment as usual. Dialectical behavioral therapies were associated with reductions in self-harm (OR, 0.28; 95% CI, 0.12-0.64) and suicidal ideation (Cohen d SMD, -0.71; 95% CI, -1.19 to -0.23) at the end of treatment, while mentalization-based therapies were associated with decreases in self-harm (OR, 0.38; 95% CI, 0.15-0.97) and suicidal ideation (Cohen d SMD, -1.22; 95% CI, -2.18 to -0.26) at the end of follow-up. The quality of evidence was downgraded because of high risk of bias overall, heterogeneity, publication bias, inconsistency, and imprecision.

CONCLUSIONS AND RELEVANCE

Although some psychotherapeutic modalities appear to be acceptable and efficacious for reducing self-harm and suicidality among children and adolescents, methodological issues and high risk of bias prevent a consistent estimate of their comparative performance.

Suicide among Polish Adolescents-A 20 Year Analysis

Background: The study aimed to analyze the burden and territorial diversification of adolescent suicide and the link between suicide attempts and selected socioeconomic variables in Poland. Methods: Rates of suicide by voivodeships for years 1999–2019 were obtained from the General Police Headquarters of Poland database. The burden of premature death was expressed in years of life lost (YLL) and costs of lost productivity, which were estimated using the human capital approach. The link between suicide rates and socioeconomic determinants has been analyzed with Pearson’s correlation coefficient. Results: Over the analyzed period, an increase in suicide attempt rates and a decrease in suicide death rates have been observed. Mean YLL and costs of lost productivity per year amounted to 11,982 and 153,172,415 PLN, respectively. Territorial diversification in suicide attempt rates corresponds to the living condition, poverty, association-based capital, and satisfaction with family situation in individual voivodeships. The number of deaths due to suicide is negatively correlated with an indicator of good living conditions. Conclusions: Our findings provide quantitative evidence of the national impact of suicide and suggest that addressing social capital and poverty may have a role in preventing adolescent mortality due to suicide.