Severity and Variability of Depression Symptoms Predicting Suicide Attempt in High-Risk Individuals

Identifying behaviour-related and physiological risk factors for suicide attempts in the UK Biobank

Suicide is a global public health challenge, yet considerable uncertainty remains regarding the associations of both behaviour-related and physiological factors with suicide attempts (SA). Here we first estimated polygenic risk scores (PRS) for SA in 334,706 UK Biobank participants and conducted phenome-wide association analyses considering 2,291 factors. We identified 246 (63.07%) behaviour-related and 200 (10.41%, encompassing neuroimaging, blood and metabolic biomarkers, and proteins) physiological factors significantly associated with SA-PRS, with robust associations observed in lifestyle factors and mental health. Further case-control analyses involving 3,558 SA cases and 149,976 controls mirrored behaviour-related associations observed with SA-PRS. Moreover, Mendelian randomization analyses supported a potential causal effect of liability to 58 factors on SA, such as age at first intercourse, neuroticism, smoking, overall health rating and depression. Notably, machine-learning classification models based on behaviour-related factors exhibited high discriminative accuracy in distinguishing those with and without SA (area under the receiver operating characteristic curve 0.909 ± 0.006). This study provides comprehensive insights into diverse risk factors for SA, shedding light on potential avenues for targeted prevention and intervention strategies.

Associations of rumination with suicidal ideation and suicide attempts amongst individuals with major depressive disorder: A 12-month longitudinal study in China

BACKGROUND

This study aimed to explore the longitudinal associations of rumination with suicidal ideation and suicide attempts in individuals with major depressive disorder (MDD).

METHODS

Participants were derived from the Depression Cohort in China study (DCC). Those who completed at least one follow-up visit during the 12 months were included in the analysis. Dimensions of rumination including brooding and reflection were each measured using five items of the Ruminative Responses Scale. Suicidal ideation was assessed using the Beck Scale for Suicide Ideation. Suicide attempts were also assessed and all were analyzed with generalized estimating equations.

RESULTS

Our final sample included 532 participants aged 18 to 59 years (mean [SD], 26.91 [6.94] years) consisting of 148 (27.8%) males and 384 (72.2%) females. After adjusting for temporal trend and potential confounders, individuals with higher levels of reflection were more likely to report suicidal ideation (AOR =1.11, 95% CI:1.01-1.22). However, no statistically significant association was found between brooding and suicidal ideation (AOR =1.06, 95% CI:0.96-1.17). Conversely, individuals with higher levels of brooding were more likely to report suicide attempts (AOR =1.13, 95% CI:1.02-1.24), while no statistically significant association was observed between reflection and suicide attempts (AOR =0.91, 95% CI:0.82-1.01).

CONCLUSION

Rumination reflects a disturbance in cognitive emotional processing and manifests in different dimensions. Our findings suggest that high levels of reflection and brooding may be associated with a higher likelihood of having suicidal ideation and suicide attempts, respectively. However, it should be interpreted with caution, given that effect sizes are small.

Role of machine learning algorithms in suicide risk prediction: a systematic review-meta analysis of clinical studies

OBJECTIVE

Suicide is a complex and multifactorial public health problem. Understanding and addressing the various factors associated with suicide is crucial for prevention and intervention efforts. Machine learning (ML) could enhance the prediction of suicide attempts.

METHOD

A systematic review was performed using PubMed, Scopus, Web of Science and SID databases. We aim to evaluate the performance of ML algorithms and summarize their effects, gather relevant and reliable information to synthesize existing evidence, identify knowledge gaps, and provide a comprehensive list of the suicide risk factors using mixed method approach.

RESULTS

Forty-one studies published between 2011 and 2022, which matched inclusion criteria, were chosen as suitable. We included studies aimed at predicting the suicide risk by machine learning algorithms except natural language processing (NLP) and image processing. The neural network (NN) algorithm exhibited the lowest accuracy at 0.70, whereas the random forest demonstrated the highest accuracy, reaching 0.94. The study assessed the COX and random forest models and observed a minimum area under the curve (AUC) value of 0.54. In contrast, the XGBoost classifier yielded the highest AUC value, reaching 0.97. These specific AUC values emphasize the algorithm-specific performance in capturing the trade-off between sensitivity and specificity for suicide risk prediction. Furthermore, our investigation identified several common suicide risk factors, including age, gender, substance abuse, depression, anxiety, alcohol consumption, marital status, income, education, and occupation. This comprehensive analysis contributes valuable insights into the multifaceted nature of suicide risk, providing a foundation for targeted preventive strategies and intervention efforts.

CONCLUSIONS

The effectiveness of ML algorithms and their application in predicting suicide risk has been controversial. There is a need for more studies on these algorithms in clinical settings, and the related ethical concerns require further clarification.

Variations in Suicide Risk and Risk Factors After Hospitalization for Depression in Finland, 1996-2017

Importance

Although incidence of suicide in depression varies remarkably temporally, risk factors have been modeled as constant and remain uncharted in the short term. How effectively factors measured at one point in time predict risk at different time points is unknown.

Objective

To examine the absolute risk and risk factors for suicide in hospitalized patients with depression starting from the first days after discharge up to 2 years and to evaluate whether the size of relative risk by factor displays temporal patterns over consecutive phases of follow-up.

Design, Setting, and Participants

This population-based study using Finnish registers (hospital discharge, population, and cause of death registers) included all hospitalizations for depression as the principal diagnosis in Finland from 1996 to 2017, with a maximum follow-up of 2 years. Data were analyzed from January 2022 to November 2023.

Main Outcomes and Measures

Incidence rate (IR), IR ratios, hazard functions, and hazard ratios for suicide by consecutive time periods (0 to 3 days, 4 to 7 days, 7 to 30 days, 31 to 90 days, 91 to 365 days, and 1 to 2 years) since discharge.

Results

This study included 193 197 hospitalizations among 91 161 individuals, of whom 51 197 (56.2%) were female, and the mean (SD) age was 44.0 (17.3) years. Altogether, patients were followed up to 226 615 person-years. A total of 1219 men and 757 women died of suicide. Incidence of suicide was extremely high during the first days after discharge (IR of 6062 [95% CI, 4963-7404] per 100 000 on days 0 to 3; IR of 3884 [95% CI, 3119-4835] per 100 000 on days 4 to 7) and declined thereafter. Several factors were associated with risk of suicide over the first days after discharge. Current suicide attempt by hanging or firearms increased the risk of suicide most on days 0 to 3 (IR ratio, 18.9; 95% CI, 3.1-59.8) and on days 0 to 7 (IR ratio, 10.1; 95% CI, 1.7-31.5). Temporal patterns of the size of the relative risk diverged over time, being constant, declining, or increasing. Clinical factors had the strongest association immediately. Relative risk remained constant among men and even increased among those with alcohol or substance use disorder.

Conclusions and Relevance

In this study, patients hospitalized for depression had extremely high risk of suicide during the first days after discharge. Thereafter, incidence declined steeply but remained high. Within the periods of the highest risk of suicide, several factors increased overall risk manyfold. Risk factors' observed potencies varied over time and had characteristic temporal patterns.

Weekly links among irritability and suicidal thoughts and behaviors in high-risk youth

BACKGROUND

Previous studies demonstrate a link between irritability and suicidal thoughts and behaviors (STBs) in youth samples. However, they have mostly assessed irritability in community samples and as a largely dispositional (i.e. trait-like) construct. Thus, it remains unclear to what extent links between irritability and STBs reflect within-person processes of elevated risk in clinically meaningful time periods.

METHODS

The present study used clinical data from 689 adolescents aged 12-19 years attending a total of 6,128 visits at a specialty Intensive Outpatient Program for depressed and suicidal youth to examine patterns in weekly assessments of irritability and STBs throughout treatment, including associations among trends and fluctuations departing from these trends via multilevel structural equation modeling. Youth completed self-report measures of irritability, depression, and STBs weekly as part of standard IOP clinical care.

RESULTS

Overall, two-thirds of variance in weekly irritable mood was accounted for by between-person differences and the remaining portion by weekly fluctuations. After controlling for depression, during weeks when youth were more irritable they experienced increased STBs. Rates of change in irritability and STBs tended to track together at early stages of treatment, but these effects were generally accounted for by depression severity.

CONCLUSIONS

Our results suggest that although changes in STBs are best accounted for by depression, irritability can be understood as a specific, proximal risk factor for youth STBs that exacerbates youth STBs in clinically informative timeframes above and beyond depression.

Identity Fusion and Aggressive Behavior Among Chinese Freshmen: The Chain Mediating Role of Depressive Mood and Sleep Quality

Aggressive behavior is considered one of the indicators of maladjustment and increases during the transition to college. Previous studies have demonstrated that having identity fusion with particular social groups significantly predicts college adjustment among freshmen. However, the relationship between identity fusion and aggressive behavior in college freshmen has rarely been studied. Thus, guided by the frustration-aggression theory, this study aimed to explore the association between identity fusion with class and aggressive behavior among Chinese college freshmen and examine the potential mediating roles of depressive mood and sleep quality. A cross-sectional survey study was carried out among 1,037 Chinese college freshmen (Mage = 19.56, SD = 1.068, 29.12% males). Class identity fusion, depressive mood, sleep quality, and aggressive behavior were measured via four self-reported questionnaires. Structural equation modeling was used to test the mediation model. Analyses showed that identity fusion was negatively related to depressive mood and aggressive behavior and positively correlated with sleep quality. The results also revealed that the direct effect of identity fusion on aggressive behavior was significant, and identity fusion can indirectly affect aggressive behavior not only through the mediation effect of depressive mood but also through the chain mediation effect of depressive mood and sleep quality. Moreover, the mediating effect of depressive mood varied by gender. These findings suggest that strategies that help freshmen promote identity fusion and those that alleviate depressive mood and sleep problem may help reduce aggressive behavior.

Physical Activity Is Associated with the Incidence of Depression in United States Adults from the NHANES 2013-18: A Cross-Sectional Study

The number of depression sufferers is rising globally. In the United States, 8% of adults over 20 years of age suffer from it, making it the most prevalent mental disorder in the country. Some lifestyle habits have been shown to favor or prevent the onset of depression; for instance, physical inactivity is associated with an increased likelihood of suffering depression, whilst multiple benefits have been attributed to performing physical activity (PA). This study aims to test whether there is a dependence between the prevalence of depression and PA, age, gender and educational level. The secondary objective was to identify the differentiating variables for depression and non-depression. This cross-sectional study is based on data from the NHANES 2013-2014, 2015-2016 and 2017-2018 editions. Some of the items in this survey were taken from preexisting questionnaires: the Patient Health Questionnaire-9 for depression screening and the Global Physical Activity Questionnaire (GPAQ) for the PA groups. The final sample was formed of 15,574 United States residents over 18 years old. After testing the data normality (p < 0.001), a descriptive analysis and the non-parametric chi-square test was conducted, as well as discriminant analysis. The results showed that there was an association between depression prevalence and PA (p < 0.001) in the general population and for both genders. Inactive participants had the highest prevalence of major depression and other depressive disorders. The discriminant analysis identified PA group (0.527), education level (0.761) and gender (-0.505) as significant variables that differentiate between participants with and without depression. The results of this research confirmed that a dependency relationship between PA group according to the GPAQ and depression prevalence according to the PHQ-9 existed in the United States adult population, and that PA group is a relevant variable to differentiate between depression sufferers and non-sufferers.

Childhood psychological maltreatment and adolescent depressive symptoms: Exploring the role of social anxiety and maladaptive emotion regulation strategies

BACKGROUND

Despite emerging evidence for the effect of childhood psychological maltreatment on adolescent depressive symptoms, the underlying processes for this effect are largely under-investigated. This study examined a conceptual framework for the effect of childhood psychological maltreatment on adolescent depressive symptoms through social anxiety disorder (SAD) and maladaptive emotion regulation strategies.

METHODS

The participants were 1649 Chinese middle school students (751 girls and 898 boys) with a mean age of 16.29 ± 1.04 years old. A moderation-mediation model hypothesized that childhood psychological maltreatment predicts adolescent depressive symptoms, with SAD as a mediator and maladaptive emotion regulation strategies as a moderator.

RESULTS

Childhood psychological maltreatment significantly positively predicted adolescent depressive symptoms, while SAD mediated the relation. Maladaptive emotion regulation strategies moderated the pathways from psychological maltreatment to depressive symptoms (but not from psychological maltreatment to SAD) and from SAD to adolescent depressive symptoms.

LIMITATIONS

Subjective measures, and the cross-sectional design are the main limitations.

CONCLUSIONS

SAD plays a mediating role in the relation between childhood psychological maltreatment and depressive symptoms. Maladaptive emotion regulation strategies exacerbate the relation between childhood psychological maltreatment and depressive symptoms, as well as the relation between SAD and depressive symptoms. These results highlight the importance of addressing social anxiety in reducing adolescent depressive symptoms by improving their cognitive emotion regulation strategies.

Childhood Maltreatment and Suicidal Thoughts and Behaviors in Young Adults

Background: Childhood maltreatment strongly predicts suicidality in young adulthood, which is increasingly common among Latina/o and Asian Americans. However, greater attention to modifiable explanatory factors is needed, particularly in ethnically minoritized populations. Aims: The current study evaluated whether the association between childhood maltreatment and suicidality may be accounted for by emotion regulation difficulties among a sample of young adults attending a large, minority-serving state university. Methods: Young adults (n = 853 participants; Mage = 22.43 years; 76.2% female) completed validated measures of suicidality, childhood maltreatment, depression, and emotion regulation difficulties. A multiple indirect effect analysis was conducted in a structural equation modeling framework. Results: Greater childhood maltreatment was associated with significantly greater emotion regulation difficulties across all six types and greater endorsement of overall suicidality. An indirect effect was found for limited access to regulation strategies only. Unexpectedly, lack of emotional awareness was associated with lower levels of ideation/attempts or threats of engaging in suicidal behavior. Limitations: The study was cross-sectional, precluding conclusions regarding causality. Conclusions: The findings suggest that, for individuals who have experienced childhood maltreatment, it is particularly important to address deficits in access to emotion regulation strategies to reduce the risk of suicidal ideation and behavior.

Depression and Suicidality: The Roles of Social Support and Positive Mental Health

OBJECTIVE

Despite being preventable, suicide remains a leading cause of death globally, with depression being one of the more prominent risk factors. This study examines the roles of social support and positive mental health in the depression-suicidality pathway.

METHODS

We utilized data from the Singapore Mental Health Study 2016. Social support and positive mental health were examined as mediators in the relationship between 12-month depression and 12-month suicidality using survey-weighted generalized structural equation modeling.

RESULTS

Overall positive mental health was found to partially mediate the relationship between depression and suicide. Of the discrete positive mental health domains, the depression-suicidality relationship was partially mediated by general coping and fully mediated by personal growth and autonomy.

CONCLUSION

While findings regarding social support were inconclusive, positive mental health may play a significant role in alleviating the effects of depression on suicidality. This highlights the multifaceted nature of suicidality and reveals positive mental health as a new area in assessing and treating at-risk people, to improve clinical outcomes.HIGHLIGHTSThe effect of depression on suicidality was partially mediated by overall positive mental health.General coping partially mediated the relationship between depression and suicidality.Personal growth and autonomy fully mediated the relationship between depression and suicidality.

Using digital phenotyping to capture depression symptom variability: detecting naturalistic variability in depression symptoms across one year using passively collected wearable movement and sleep data

Major Depressive Disorder (MDD) presents considerable challenges to diagnosis and management due to symptom variability across time. Only recent work has highlighted the clinical implications for interrogating depression symptom variability. Thus, the present work investigates how sociodemographic, comorbidity, movement, and sleep data is associated with long-term depression symptom variability. Participant information included (N = 939) baseline sociodemographic and comorbidity data, longitudinal, passively collected wearable data, and Patient Health Questionnaire-9 (PHQ-9) scores collected over 12 months. An ensemble machine learning approach was used to detect long-term depression symptom variability via: (i) a domain-driven feature selection approach and (ii) an exhaustive feature-inclusion approach. SHapley Additive exPlanations (SHAP) were used to interrogate variable importance and directionality. The composite domain-driven and exhaustive inclusion models were both capable of moderately detecting long-term depression symptom variability (r = 0.33 and r = 0.39, respectively). Our results indicate the incremental predictive validity of sociodemographic, comorbidity, and passively collected wearable movement and sleep data in detecting long-term depression symptom variability.

Musclin prevents depression-like behavior in male mice by activating urocortin 2 signaling in the hypothalamus

Introduction

Physical activity is recommended as an alternative treatment for depression. Myokines, which are secreted from skeletal muscles during physical activity, play an important role in the skeletal muscle-brain axis. Musclin, a newly discovered myokine, exerts physical endurance, however, the effects of musclin on emotional behaviors, such as depression, have not been evaluated. This study aimed to access the anti-depressive effect of musclin and clarify the connection between depression-like behavior and hypothalamic neuropeptides in mice.

Methods

We measured the immobility time in the forced swim (FS) test, the time spent in open arm in the elevated-plus maze (EPM) test, the mRNA levels of hypothalamic neuropeptides, and enumerated the c-Fos-positive cells in the paraventricular nucleus (PVN), arcuate nucleus (ARC), and nucleus tractus solitarii (NTS) in mice with the intraperitoneal (i.p.) administration of musclin. Next, we evaluated the effects of a selective corticotropin-releasing factor (CRF) type 1 receptor antagonist, selective CRF type 2 receptor antagonist, melanocortin receptor (MCR) agonist, and selective melanocortin 4 receptor (MC4R) agonist on changes in behaviors induced by musclin. Finally we evaluated the antidepressant effect of musclin using mice exposed to repeated water immersion (WI) stress.

Results

We found that the i.p. and i.c.v. administration of musclin decreased the immobility time and relative time in the open arms (open %) in mice and increased urocortin 2 (Ucn 2) levels but decreased proopiomelanocortin levels in the hypothalamus. The numbers of c-Fos-positive cells were increased in the PVN and NTS but decreased in the ARC of mice with i.p. administration of musclin. The c-Fos-positive cells in the PVN were also found to be Ucn 2-positive. The antidepressant and anxiogenic effects of musclin were blocked by central administration of a CRF type 2 receptor antagonist and a melanocortin 4 receptor agonist, respectively. Peripheral administration of musclin also prevented depression-like behavior and the decrease in levels of hypothalamic Ucn 2 induced by repeated WI stress.

Discussion

These data identify the antidepressant effects of musclin through the activation of central Ucn 2 signaling and suggest that musclin and Ucn 2 can be new therapeutic targets and endogenous peptides mediating the muscle-brain axis.

Suicidality and its associated factors among mood disorder patients in emergency department in China: a comparative study using propensity score matching approach

Suicidality in mood disorder patients is common, especially in emergency department (ED), but the patterns and associated factors of suicidality are not clear. This study compared biomarkers and mental health symptoms (i.e., depression, anxiety, and psychiatric symptoms) between mood disorder patients with and without the whole range of suicidality comprising suicidal ideation (SI), suicide plan (SP), and suicide attempt (SA). This cross-sectional, comparative, convenient-sampling study was conducted between January 2021 and March 2022, in emergency department of Beijing Anding Hospital, China. Patients with mood disorders at a psychiatric emergency department were assessed, with measurements of suicidality, biomarkers, depressive, anxiety, and psychiatric symptoms were assessed using the 24 items-Hamilton Depression Rating Scale (HAMD-24), Hamilton Anxiety Rating Scale (HAMA), Young Manic Rating Scale (YMRS) and Brief Psychiatric Rating Scale (BPRS), respectively. The propensity score matching (PSM) method was used to identify patients in mood disorder with and without SI, SP, and SA. A generalized linear model (GLM) was used to assess the differences in biomarkers, depressive, anxiety, and psychiatric symptoms between patients in mood disorder with and without SI, SP, and SA. In total, 898 participated in this survey and completed the assessment. Illness duration was significantly negatively associated with SA (OR = 0.969, 95%CI = 0.939-0.999, P = 0.046). HAMD-24 total score was significantly positively associated with the SI (OR = 1.167, 95%CI = 1.134-1.201, p < 0.001), SP (OR = 1.159, 95%CI = 1.126-1.192, p < 0.001) and SA (OR = 1.189, 95%CI = 1.144-1.235, p < 0.001) of the matched samptched sample. However, YMRS total score was significantly negatively associated with the SI (OR = 0.928, 95%CI = 0.905-0.951, p < 0.001), SP (OR = 0.920, 95%CI = 0.897-0.944, p < 0.001) and SA (OR = 0.914, 95%CI = 0.890-0.938, p < 0.001) of the matched sample after adjusting for age, gender, marital status, and occupation. The duration of illness, severity of depressive symptoms and severity of manic symptoms appeared to be more likely to influence suicidality. Considering the significant risk of suicide in mood disorders on psychiatric emergency care, timely treatment and effective management of suicidality in this population group need to be developed.

The role of premeditation in suicide: Identifying factors associated with increased planning among suicide decedents

INTRODUCTION

Suicide premeditation is a critical factor to consider when assessing suicide risk. Understanding which individuals are more or less likely to plan their suicidal behavior can shed light on how suicidal thoughts turn into actions.

METHOD

The present study used psychological autopsy data to identify factors associated with level of premeditation among 131 adults who died by suicide.

RESULTS

Logistic regression analyses indicated that suicide decedents with higher premeditation scores had higher odds of being diagnosed with a depressive disorder and choosing a violent suicide method, specifically a firearm. Individuals with lower premeditation scores had higher odds of being diagnosed with a polysubstance use disorder.

CONCLUSION

Suicide decedents exhibiting greater premeditation before their deaths were different in several ways from suicide decedents exhibiting less premeditation. A better understanding of suicide premeditation can ultimately aid in the development of improved risk assessments and targeted safety interventions for those struggling with suicidal thoughts.

Clinical predictors of suicidal ideation, suicide attempts and suicide death in depressive disorder: a systematic review and meta-analysis

Patients with depressive disorders are especially prone to suicide risk. Among the clinical predictors of suicidality, those specifically related to depressive disorders have not been accurately detailed. Our aim was to conduct a systematic review and meta-analysis of studies reporting longitudinal predictors of suicidal ideation, suicide attempts and suicide death within depression, including diagnostic subtypes, symptoms, clinical course, and assessment scales. A systematic search of the literature between 2001 and 2022 identified 4422 references, among which 19 studies providing 45 different predictors of suicidality met the inclusion criteria. Random effects meta-analyses were performed for 22 predictors, three for suicidal ideation, eleven for suicide attempts and eight for suicide death. Heterogeneity and publication bias were inspected through I2 tests and Egger's tests respectively. Meta-analysis results showed that severity of hopelessness predicted suicidal ideation and suicide attempts. History of suicide attempts, suicidal ideation, severe depression, and psychotic symptoms predicted subsequent suicide attempts and suicide death. Time to full remission and sleep disturbances were also found as relevant predictors of future suicide behaviours. This review specifies which predictors of suicidality within the clinical features of depression will help clinicians and policy makers to better prevent suicide risk in patients with depressive disorders. Further longitudinal studies are needed to reliably assess the predictive ability of our results and to analyse other possible clinical predictors to prevent suicidality, especially with regard to suicidal ideation.

Predicting internalizing symptoms with machine learning: identifying individuals that need care

Objective The current project aims to identify individuals in urgent need of mental health care, using a machine learning algorithm (random forest). Comparison/contrast with conventional regression analyses is discussed. Participants: A total of 2,409 participants were recruited from an anonymous university, including undergraduate and graduate students, faculty, and staff. Methods: Answers to a COVID-19 impact survey, the Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder-7 (GAD-7) were collected. The total scores of PHQ-9 and GAD-7 were regressed on six composites that were created from the questionnaire items, based on their topics. A random forest was trained and validated. Results: Results indicate that the random forest model was able to make accurate, prospective predictions (R2 = .429 on average) and we review variables that were deemed predictively relevant. Conclusions: Overall, the study suggests that predictive models can be clinically useful in identifying individuals with internalizing symptoms based on daily life disruption experiences.

Comorbidity of anxiety/affective, conduct/antisocial, attention deficit, and alcohol use disorders with suicidal behaviors in an American Indian community sample of adults and adolescents

AIMS

To study the associations of anxiety/affective disorders, conduct/antisocial disorders (ASPD/CD), attention deficit disorders (ADHD), and alcohol use disorders (AUD) with suicidal behaviors in an American Indian (AI) community sample of adolescents and adults.

METHODS

Participants were AI (360 adolescents, 925 adults) recruited from reservations who were assessed with the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA).

RESULTS

Among AI adults (mean age = 33 years), 17% percent reported lifetime experiences of suicidal thoughts (ideation and/or plans) and 14% reported suicidal acts (including either a suicide attempt history or verified death by suicide; n = 19 deaths). Among AI adolescents (mean age = 15 years), 20% experienced suicidal thoughts and 9% experienced suicidal acts (including 3 deaths). In logistic regression analyses, suicidal thoughts were significantly associated with lifetime diagnoses of affective disorder, CD and ADHD in adolescents, and with anxiety disorder, affective disorder, and ASPD/CD in adults. Suicidal acts were associated with affective disorder, ADHD, and alcohol drinking in adolescents and with anxiety disorder, ASPD/CD and AUD in adults. The number of comorbid disorders greatly increased the risk of both suicidal thoughts and acts among both adolescents and adults.

CONCLUSIONS

In addition to affective disorders, both ADHD and CD in adolescents, and ASPD in adults, demonstrated an association with suicidal thoughts. Alcohol use by adolescents and AUD among adults also were associated with suicidal attempts in this AI sample. These findings suggest need for additional research and potential integration of alcohol in screening and intervention programs focused on the prevention of suicide among AI.

Mood Disorders and Aggressive Traits Mediate Effects of Reported Childhood Adversity on Suicide Attempt Risk

BACKGROUND

Childhood adversity (CA) is linked to suicidal behavior as well as to mood disorders and aggressive traits. This raises the possibility that depression and aggressive traits mediate the relationship of childhood adversity to suicide risk. Moreover, it is not known if they operate independently or interactively.

AIMS

To determine whether, and how, mood disorders and aggressive traits mediate the effects of reported physical and sexual abuse on future suicidal behavior.

METHODS

Five hundred and forty-eight subjects, offspring of parents with mood disorders, were interviewed at baseline and at yearly follow-ups with questionnaires assessing aggression, mood disorders, and suicidal behavior. The mediation analysis involved a three-step process, testing the relationships between (1) CA and attempt; (2) CA and putative mediators; and (3) putative mediators and suicide attempt, adjusting for CA.

RESULTS

Aggressive trait severity and mood disorder onset each mediated the relationship between CA and future suicide attempts. Greater aggression severity also raised the hazard of the development of a mood disorder. If aggressive trait severity was clearly elevated, then onset of mood disorder did not increase further the hazard of the suicide attempt. Including family as a random effect had a much bigger effect on attempt outcome for physical abuse compared with sexual abuse.

CONCLUSIONS

Amelioration of aggressive traits and treatment of mood disorders in CA-exposed offspring of a parent with a mood disorder may prevent future suicide attempts and may reduce the risk of mood disorder. Familial factors influence the impact of childhood physical abuse but not sexual abuse. HIGHLIGHTSChildhood Adversity (CA) predicted future mood disorder and aggression severity.Depression and aggression mediate the relationship between CA and suicide attempts.When one mediator is present, the presence of the other does not increase the hazard.Between family variation contributed much more to suicidal behavior outcomes relative to the effect of physical abuse, but sexual abuse contributed to suicidal outcomes more than family variation.

Risks & Protective Factors for Depression & Suicide Among Hawai'i Agricultural Producers

Studies have consistently shown that agricultural producers in the continental United States have disproportionately high rates of depression and suicide as compared to other occupations. It is not known whether this is true in Hawai'i, which is both geographically distinct and ethnically diverse. To examine rates of depression and suicide as well as potential risk and protective factors, a state-wide mental health needs assessment was conducted from November 2021 to September 2022. We conducted a survey with a nonprobability-based convenience sample targeting agricultural producers across Hawai'i, and performed descriptive statistics and logistic regression analyses. In a sample of 408 respondents, 35% (n = 143) had clinical depression symptomatology, and 8% (n = 33) had suicidal ideation based on the Patient Health Questionnaire-9. Older age was slightly protective in that every year of increase in age was associated with 0.98 times (95% CI: 0.96, 0.99) reduced odds of depression symptomatology, and 0.96 times (95% CI:0.94, 0.98) reduced odds of suicidal ideation. Identifying as East Asian had 2.04 times (95% CI: 1.16, 3.61) higher odds of depression symptomatology, and Southeast Asian had 3.04 times odds (95% CI:1.15, 8.00) of suicidal ideation. However, in the presence of stress and coping variables, the demographic factors became statistically non-significant. Instead, feeling stressed, uncertainty as the stressor, and media-focused coping were significant risk factors in increasing two to eight times the odds of depressive symptoms. For suicidal ideation, depression symptomatology increased odds by 31.95 (95% CI: 5.60-182.32), using media-focused coping increased 5.20 odds (95% CI: 1.66, 16.27), but problem-focused coping decreased 0.32 times odds (0.10, 0.99). Culturally specific prevention and intervention measures should be tailored for Hawai'i agricultural producers with an emphasis toward younger, East, and Southeast Asian producers and attention toward providing skillful coping strategies for effective stress regulation and management.

The associations between academic stress and depression among college students: A moderated chain mediation model of negative affect, sleep quality, and social support

BACKGROUND

Growing competition in tight job market and academic excellence as a social norm in Asian culture have made Chinese college students burdened with immense academic stress.

OBJECTIVES

This study aimed to explore the associations between academic stress and depression, and the mediating roles of negative affect and sleep quality, as well as the moderating role of social support in the relationship between negative affect and sleep quality.

METHODOLOGY

A convenience sample of 221 male and 479 female college students aged between 17 and 25 completed questionnaires on academic stress, depression, negative affect, sleep quality and social support.

RESULTS

Results indicated that academic stress could not only directly affect depression (b = 0.31, p < 001), but also affect depression through the mediation role of negative affect and sleep quality. The chain mediating effects includes three paths, namely, the mediating role of negative affect (indirect effect = 0.21, percentage of total effect = 69.58 %), the mediating role of sleep quality (indirect effect = 0.06, percentage of total effect = 21.03 %), and the chain mediating role of negative affect and sleep quality (indirect effect = 0.06, percentage of total effect = 19.86 %). Social support moderated the adverse influence of negative affect on sleep quality. Social support decreases the impact of negative affect on sleep quality. Specifically, the association between negative affect and sleep quality was stronger for college students with low (bsimple = 0.44, p < 0.001) social support than those with high (bsimple = 0.32, p < 0.001) social support.

IMPLICATIONS

The results advanced our understanding of how academic stress affects college students' depression. These findings provide implications on the cultivation of stress coping strategies, promotion of emotion regulation skills, exaltation of sleep quality, and improvement of the social support level aiming for future depression preventions and interventions. Specific measures include setting up psychological health courses, teaching emotion management strategies, and establishing web-based programme steming from acceptance and commitment therapy. It should be noted that the cross-sectional design means the causal associations among the variables could not be determined.

The temporal relationship between depressive symptoms and self-rated health across adulthood

Objective: Depressive symptoms have been found to relate to diminished self-rated health (SRH), which is a reliable index of general health. Despite such associations, there is limited research examining the bidirectional temporal relationship between these variables. The current study is the first to investigate the longitudinal relationship between depressive symptoms and SRH utilizing a cross-lagged panel analysis in a sample that spans adulthood (ages 18-93).Method: Data from the Virginia Cognitive Aging Project were used to examine the temporal relationship between depressive symptoms and SRH in a cross-lagged panel analysis using structural equation modeling.Results: A bidirectional temporal relationship, which was not moderated by age, was established between depressive symptoms and SRH.Conclusion: This article is the first to demonstrate that depressive symptoms and SRH influence each other reciprocally over time across adulthood, even after controlling for relevant variables. Considering the ubiquity and ramifications of depressive symptoms among American adults, these results highlight the importance of investigating mechanisms that could elucidate the link between the variables in question.

The Morbidity and Associated Factors of Depression in Caregivers of Patients with Depressive Disorder

Objective

Depressive disorder significantly impacts patients' daily living activities and quality of life. Caregivers of patients with depression may also suffer from psychological distress related to the chronic burden of caring for the patient's mood changes. The purpose of this study was to evaluate the morbidity and associated factors of depression in caregivers of patients with depressive disorder.

Methods

In this study, we used a cross-sectional design with consecutive sampling. Study subjects were recruited from the psychiatric outpatient clinic of a medical center from August 2021 to June 2022. Caregivers of depressive disorder patients were enrolled and assessed using the Mini International Neuropsychiatric Interview, Hospital Anxiety and Depression Scale (HADS), Suicide Assessment Scale (SAS), Stigma Scale of the Explanatory Model Interview Catalogue (EMIC), and Family APGAR Index.

Results

Of the 120 caregivers that completed the study, 59.2% (n=71) were females. The most common psychiatric diagnosis was depressive disorders (25.8%), followed by anxiety disorders (17.5%) and insomnia disorder (15.8%); 54.2% of the caregivers had a psychiatric diagnosis. Using logistic regression analysis, we found that anxiolytics/hypnotics use (OR=5.58; 95% CI, 1.84-16.96; p<0.01), higher suicide risk (SAS) (OR=1.10; 95% CI, 1.05-1.16; p<0.001), and lower family support (APGAR scores) (OR=0.82; 95% CI, 0.71-0.94; p<0.01) were three significant associated factors.

Conclusion

Depression was the most prevalent psychiatric diagnosis in caregivers of patients with depressive disorder. Early psychiatric diagnosis for caregivers of patients with depression is crucial to offering suitable support and treatment and may improve caregivers' quality of life.

Rasch analysis of the beck depression inventory in a homeless and precariously housed sample

The approach to analysis of and interpretation of findings from the Beck Depression Inventory (BDI), a self-report questionnaire, depends on sample characteristics. To extend work using conventional BDI scoring, the BDI's suitability in assessing symptom severity in a homeless and precariously housed sample was examined using Rasch analysis. Participants (n=478) recruited from an impoverished neighbourhood in Vancouver, Canada, completed the BDI. Rasch analysis using the partial credit model was done, and the structural validity, unidimensionality, and reliability of the BDI were studied. A receiver operating characteristic curve determined a Rasch cut-off score consistent with clinical depression, and Rasch scores were correlated with raw scores. Good fit to the Rasch model was observed after rescoring all items and removing Item 19 (Weight Loss), and unidimensionality and reliability were satisfactory. Item 9 (Suicidal Wishes) represented the most severe symptom. Rasch-based scores detected clinical depression with moderate sensitivity and specificity, and were positively correlated with conventional scores. The BDI in a community-based sample of homeless and precariously housed adults satisfied Rasch model expectations in a 20-item format, and is suitable for assessing symptom severity. Future research on depression in similar samples may reveal more information on using specific symptoms to determine clinical significance.

Relationship between Mediterranean diet and depression in South Korea: the Korea National Health and Nutrition Examination Survey

Background

Several studies have shown that adherence to the Mediterranean diet is associated with a lower risk of depression; however, little is known about the Asian population. This study investigated the relationship between adherence to the Mediterranean diet and depression in a sample of the South Korean population.

Methods

In total, 5,849 adults from the 2014 and 2016 Korea National Health and Nutrition Examination Surveys were included in the study. The Mediterranean diet adherence was measured using a modified alternate Mediterranean diet score (mMED) developed to adjust for Korean dietary patterns. The mMED scores using the Food Frequency Questionnaire were divided into four categories (0-2, 3-4, 5-6, and 7-9 points). Subjects with depression were defined as having moderate-to-severe depressive symptoms using the Patient Health Questionnaire-9, with a cutoff value of 10. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). A subgroup analysis was performed based on sex.

Results

The results of logistic regression analysis indicated that individuals with higher mMED were 42-73% less likely to report depression compared to individuals with the lowest mMED [ORs (95% CIs) =0.58 (0.37-0.90), 0.50 (0.31-0.80), 0.27 (0.15-0.47)] after adjusting for socio-demographic and health-related variables. In women, individuals with mMED of 7-9 had 71% lower odds of depression [ORs (95% CIs): 0.29 (0.13-0.64)]. In men, individuals with mMED of 5-9 had 55% [ORs (95% CIs): 0.45 (0.23-0.91)] to 79% [ORs (95% CIs): 0.21 (0.08-0.57)] lower odds of depression.

Conclusion

This study suggests that adherence to the Mediterranean diet is inversely associated with depression in both men and women among Korean adults. This study provides evidence that a Mediterranean diet is crucial in preventing depressive symptoms in Asian populations.

Smaller cornu ammonis (CA3) as a potential risk factor for suicidal behavior in mood disorders

Mood disorders and suicidal behavior have moderate heritability and familial transmission, and are associated with smaller hippocampal volumes. However, it is unclear whether hippocampal alterations reflect heritable risk or epigenetic effects of childhood adversity, compensatory mechanisms, illness-related changes, or treatment effects. We sought to separate the relationships of hippocampal substructure volumes to mood disorder, suicidal behavior, and risk and resilience to both by examining high familial risk individuals (HR) who have passed the age of greatest risk for psychopathology onset. Structural brain imaging and hippocampal substructure segmentation quantified Cornu Ammonis (CA1-4), dentate gyrus, and subiculum gray matter volumes in healthy volunteers (HV, N = 25) and three groups with one or more relatives reporting early-onset mood disorder and suicide attempt: 1. Unaffected HR (N = 20); 2. HR with lifetime mood disorder and no suicide attempt (HR-MOOD, N = 25); and 3. HR with lifetime mood disorder and a previous suicide attempt (HR-MOOD + SA, N = 18). Findings were tested in an independent cohort not selected for family history (HV, N = 47; MOOD, N = 44; and MOOD + SA, N = 21). Lower CA3 volume was found in HR (vs. HV), consistent with the direction of previously published findings in MOOD+SA (vs. HV and MOOD), suggesting the finding reflects a familial biological risk marker, not illness or treatment-related sequelae, of suicidal behavior and mood disorder. Familial suicide risk may be mediated in part by smaller CA3 volume. The structure may serve as a risk indicator and therapeutic target for suicide prevention strategies in high-risk families.

Network analysis of comorbid depression, suicidality and biomarkers on HPA axis among mood disorder patients to psychiatric emergency services

Rapid assessment and intervention of suicide risk are common and challenging in psychiatric emergency departments (PED). It is unclear whether distinct pathophysiological processes exist among depressive patients with suicidality. This study examined the network structures of biomarkers on Hypothalamic-Pituitary-Adrenal (HPA) axis, such as Adrenocorticotropic hormone (ACTH) and Corticosterone (Cort), as well as suicidality and depressive symptoms in mood disorder patients in PED. Mood disorder patients in PED were assessed with the measurements of suicidality and depressive symptoms, respectively. A network analysis was performed to identify central symptoms and bridge symptoms of this network and their links to ACTH and Cort. Network stability was examined using the case-dropping procedure. The Network Comparison Test (NCT) was conducted to evaluate whether network characteristics differed by gender. A total of 1815 mood disorder patients were recruited. The prevalence of SI was 31.2% (95% CI: 28.15-34.21%), SP was 30.4% (95% CI: 27.39-33.41%), SA was 30.62% (95% CI: 27.61-33.64%) among psychiatric outpatients. The mean score of HAMD-24 was 13.87 ± 8.02. Network analysis revealed that 'Somatic anxiety' had the highest expected centrality, followed by 'Hopelessness' and 'Suicide attempt'. 'Corticosterone' and 'Retardation' may be the main bridge symptoms between depressive symptoms and the suicidality community. The network model showed a high degree of stability. Gender did not significantly influence the network structure. The central symptoms and key bridge symptoms identified could be potential targets for interventions of the HPA axis, which is designed for regular screening of a range of suicidal activity. In the light of this, timely treatment should be provided for psychiatric emergency care.

Impaired behavioral inhibitory control of self-injury cues between adolescents with depression with self-injury behavior and those without during a two-choice oddball task: an event-related potential study

Background

This study aimed to objectively evaluate the severity of impulsivity [behavior inhibitory control (BIC) impairment] among adolescents with depression. In particular, those involved in non-suicidal self-injury (NSSI) behaviors, compared with those engaged in suicidal behaviors and adolescents without any self-injury behavior, using event-related potentials (ERPs) and event-related spectral perturbation (ERSP) within the two-choice oddball paradigm.

Methods

Participants with a current diagnosis of major depressive disorder (MDD) engaged in repetitive NSSI for five or more days in the past year (n = 53) or having a history of at least one prior complete suicidal behavior (n = 31) were recruited in the self-injury group. Those without self-injury behavior were recruited in the MDD group (n = 40). They completed self-report scales and a computer-based two-choice oddball paradigm during which a continuous electroencephalogram was recorded. The difference waves in P3d were derived from the deviant minus standard wave, and the target index was the difference between the two conditions. We focused on latency and amplitude, and time-frequency analyses were conducted in addition to the conventional index.

Results

Participants with self-injury, compared to those with depression but without self-injury, exhibited specific deficits in BIC impairment, showing a significantly larger amplitude. Specifically, the NSSI group showed the highest value in amplitude and theta power, and suicidal behavior showed a high value in amplitude but the lowest value in theta power. These results may potentially predict the onset of suicide following repetitive NSSI.

Conclusion

These findings contribute to substantial progress in exploring neuro-electrophysiological evidence of self-injury behaviors. Furthermore, the difference between the NSSI and suicide groups might be the direction of prediction of suicidality.

Association between the epigenetic lifespan predictor GrimAge and history of suicide attempt in bipolar disorder

Bipolar disorder (BD) has been previously associated with premature mortality and aging, including acceleration of epigenetic aging. Suicide attempts (SA) are greatly elevated in BD and are associated with decreased lifespan, biological aging, and poorer clinical outcomes. We investigated the relationship between GrimAge, an epigenetic clock trained on time-to-death and associated with mortality and lifespan, and SA in two independent cohorts of BD individuals (discovery cohort - controls (n = 50), BD individuals with (n = 77, BD/SA) and without (n = 67, BD/non-SA) lifetime history of SA; replication cohort - BD/SA (n = 48) and BD/non-SA (n = 47)). An acceleration index for the GrimAge clock (GrimAgeAccel) was computed from blood DNA methylation (DNAm) and compared between groups with multiple general linear models. Differences in epigenetic aging from the discovery cohort were validated in the independent replication cohort. In the discovery cohort, controls, BD/non-SA, and BD/SA significantly differed on GrimAgeAccel (F = 5.424, p = 0.005), with the highest GrimAgeAccel in BD/SA (p = 0.004, BD/SA vs. controls). Within the BD individuals, BD/non-SA and BD/SA differed on GrimAgeAccel in both cohorts (p = 0.008) after covariate adjustment. Finally, DNAm-based surrogates revealed possible involvement of plasminogen activator inhibitor 1, leptin, and smoking pack-years in driving accelerated epigenetic aging. These findings pair with existing evidence that not only BD, but also SA, may be associated with an accelerated biological aging and provide putative biological mechanisms for morbidity and premature mortality in this population.

Understanding the mediated relationship between moral distress, depression, and suicide risk in undergraduate nursing students

BACKGROUND

Nursing students are at higher risk for depression, suicide, and other mental health concerns as compared to the general college student population. Moral distress and other ethical issues may be a significant source of psychological harm within nursing student experiences and warrants further attention.

PURPOSE

The purpose of this study was to understand the mediating effect of depression on the relationship between moral distress and suicide risk among undergraduate nursing students.

METHODS

This cross-sectional analysis was derived from a larger sequential mixed methods study. The first phase was an online survey completed by a national sample of N = 679 nursing students in the United States.

FINDINGS

The relationship between moral distress and suicide risk was fully mediated by depression and statistically significant at the alpha = 0.05 level.

CONCLUSION

All three psychological variables (depression, moral distress, suicide risk) impact nursing students and require innovative solutions within nursing and educational programs.

Implementing Evidence-Based Suicide Prevention Strategies for Greatest Impact

Suicide remains a leading cause of death in the United States and globally. In this review, epidemiological trends in mortality and suicide risk are presented, with consideration given to the impact of the COVID-19 pandemic. A public health model of suicide prevention with a community and clinical framework, along with advances in scientific discovery, offer new solutions that await widespread implementation. Actionable interventions with evidence for reducing risk for suicidal behavior are presented, including universal and targeted strategies at community, public policy, and clinical levels. Clinical interventions include screening and risk assessment; brief interventions (e.g., safety planning, education, and lethal means counseling) that can be done in primary care, emergency, and behavioral health settings; psychotherapies (cognitive-behavioral, dialectical behavior, mentalization therapy); pharmacotherapy; and systemwide procedures for health care organizations (training, policies, workflow, surveillance of suicide indicators, use of health records for screening, care steps). Suicide prevention strategies must be prioritized and implemented at scale for greatest impact.

Depression and suicidality severity among TRD patients after 1-year under standard of care: Findings from the TRAL study, a multicenter, multinational, observational study in Latin America

INTRODUCTION

Treatment resistant depression (TRD) is one of the most pressing issues in mental healthcare in LatAm. However, clinical data and outcomes of standard of care (SOC) are scarce. The present study reported on the Treatment-Resistant Depression in America Latina (TRAL) project 1-year follow-up of patients under SOC assessing clinical presentation and outcomes.

MATERIALS AND METHODS

420 patients with clinical diagnoses of TRD from Argentina, Brazil, Colombia and Mexico were included in a 1-year follow-up to assess clinical outcomes of depression (MADRS) and suicidality (C-SSRS), as well as evolution of clinical symptoms of depression. Patients were assessed every 3 months and longitudinal comparison was performed based on change from baseline to each visit and end of study (12 months). Socio demographic characterization was also performed.

RESULTS

Most patients were female (80.9%), married (42.5%) or single (34.4%), with at least 10 years of formal education (71%). MDD diagnosis was set at 37.29 (SD=14.00) years, and MDD duration was 11.11 years (SD=10.34). After 1-year of SOC, 79.1% of the patients were still symptomatic, and 40% of the patients displayed moderate/severe depression. Only 44.1% of the patients achieved a response (≥50% improvement in MADRS), and 60% of the sample failed to achieve remission. Suicidal ideation was reported by more than half of the patients at the end of study.

CONCLUSIONS

Depression and suicidality symptoms after a 1-year of SOC is of great concern. Better therapeutic options are needed to tackle this debilitating and burdensome disease.

Depression, Anxiety and Antidepressants and Anxiolytics Use in Spanish Informal Caregivers according to the Physical Activity Frequency: EHSS 2014–2020

Depression and anxiety are two of the most common mental diseases both in formal and nonformal caregivers. Physical activity during leisure time seems to have benefits on their practitioner’s mental health. This study aimed to analyze the associations between physical activity frequency (PAF) and depression and anxiety status, as well as antidepressant and anxiolytic use in Spanish nonformal caregivers. A cross-sectional study with data from the 2014 and 2020 European Health Interview Surveys in Spain (EHSS) including 4520 Spanish nonformal caregivers was carried out. The PAF was found to be related to depression and anxiety, as well as antidepressants and anxiolytics use (p < 0.001), with the highest proportions of these variables found in the inactive population (p < 0.05), while the active and very active populations showed the lowest proportions (p < 0.05). Weak but statistically significant correlations were found between all variables of interest (p < 0.001). Being female, older, and dedicating more hours per week to caregiving and caring for nonfamily members were found to have increased risks of depression, anxiety and antidepressants or anxiolytics use. Nonformal caregivers who were not physically active during their leisure time had higher mental disorders and psychotropic drug use proportions than the active and very active caregivers. Thus, increasing nonformal caregivers’ PAF could be a protective tool.

Risk and Protective Factors in Ecuadorian Adolescent Survivors of Suicide

Suicide is one of the main causes of death among the adolescent population, which is why it is considered an important mental-health problem. In addition to this situation, for each suicide, the group of people who survive it (known as suicide survivors) can present serious emotional affectations, becoming a population at risk for this problem. The purpose of this study was to analyze the effect of suicide-survivor status on risk factors and protective factors for suicide. A total of 440 adolescents with a mean age of 15.78 (SD = 1.74) participated, who were divided according to survivor status, identified as the SV group (79 cases), and non-survivors, identified as the NSV group—adolescents that did not have experience or contact with a suicide attempt (361 cases). A questionnaire of sociodemographic characterization and risk conditions, the Alexian Brother Urge to Self-Injure (ABUSI), the Plutchik Suicide Risk Scale, the Multidimensional Scale of Perceived Social Support, and the Cognitive and Affective Empathy Test (TECA) were applied. Descriptive statistics, mean difference for independent samples, contingency tables, X2 statistic, Fisher’s exact statistic, and Cohen’s d coefficient were used. The results show significant differences between SV and NSV participants in risk and protective factors regarding the presence of a greater adoption of perspective and emotional understanding. On the other hand, NSV adolescents presented higher scores of perceived social supports regarding risk factors, and there was a higher proportion of a history of suicide attempt, severity/hospitalization, impulse to self-harm, and level of suicidal risk in the SV group. The need to incorporate forms of suicide prevention with the survivor population is discussed, increasing the possibilities of postvention.

Suicidal ideation in the general population in China after the COVID-19 pandemic was initially controlled

BACKGROUND

The COVID-19 pandemic increases the risk of psychological problems including suicidal ideation (SI) in the general population. In this study, we investigated the risk factors of SI after the COVID-19 pandemic was initially controlled in China.

METHODS

We conducted an online questionnaire via JD Health APP in China in June 2020. Demographic data, feelings and experiences related to the COVID-19 pandemic and psychological problems were collected. The participants (n = 14,690) were divided into the non-SI and SI groups. A binary logistic regression analysis was used to examine the correlates of SI.

RESULTS

Nine percent of the participants (1328/14690) reported SI. The regression analysis showed that SI was positively associated with ethnic minority (OR = 1.42 [1.08-1.85]), age (e.g. 18-30 years: OR = 2.31 [1.67-3.20]), having history of mental disorders (OR = 2.75 [2.27-3.35]), daily life disturbance due to health problems (OR = 1.67 [1.38-2.01]), being around someone with the COVID-19 (OR = 1.58 [1.30-1.91]), being uncertain about effective disease control (OR = 1.23 [1.03-1.46]), and having depressive symptoms (OR = 4.40 [3.59-5.39]), insomnia symptoms (OR = 2.49 [2.13-2.90]) or psychological distress (OR = 1.87 [1.59-2.18]).

LIMITATIONS

The main limitation is that the cross-sectional design of this study could not allow us to further explore the causality of SI.

CONCLUSIONS

The prevalence of SI was relatively high in general population after the COVID-19 pandemic was initially controlled in China. SI should be monitored continually after the COVID-19 pandemic.

Hospital inpatient suicides: A retrospective comparison between psychiatric and non-psychiatric inpatients in Milan healthcare facilities

INTRODUCTION

Inpatient suicide in hospitals is a worrying phenomenon that has received little attention. This study retrospectively explored the socio-demographic, clinical, and suicide-related characteristics of hospital inpatient suicides in Milan, Italy, which were collected at the Institute of Forensic Medicine during a twenty-eight-year period (1993-2020). In particular, this study compared the features of hospital inpatient suicides in patients with and without psychiatric diagnoses.

METHODS

Data were collected through the historical archive, annual registers, and autopsy reports, in certified copies of the originals deposited with the prosecutors of the courts.

RESULTS

Considering the global sample, inpatients were mainly men (N = 128; 64.6%), with a mean age of 56.7 years (SD ± 19.8), of Italian nationality (N = 176; 88.9%), admitted to non-psychiatric wards (N = 132; 66.7%), with a single illness (N = 111; 56.1%), treated with psychotropic medications (N = 101; 51%), who used violent suicide methods (N = 177; 89.4%), died of organic injuries (N = 156; 78.8%), and outside the buildings (N = 114; 72.7%). Comparing psychiatric and non-psychiatric inpatients, suicide cases with a non-psychiatric diagnosis were predominantly men (N = 48; 76.2%), hospitalized in non-psychiatric wards (N = 62; 98.4%), assuming non-psychotropic drugs (N = 37; 58.7%), and died in outside hospital spaces (N = 54; 85.7%).

CONCLUSIONS

A fuller characterization of suicide among hospitalized inpatients requires systematic and computerized data gathering that provides for specific information. Indeed, this could be valuable for inpatient suicide prevention strategies as well as institutional policies.

Distinct trajectories of suicidal behaviors throughout the university stage and associated risk and protective factors: A large-scale prospective study

BACKGROUND

Suicide is a major public health concern, especially among adolescents and young adults. Although research has begun to explore the developmental trajectories of suicide-related outcomes, most have thus far focused on children and adolescents. The current study extends existing literature by identifying subgroup trajectories and related factors of college students over a two-year period.

METHODS

The data used in this study was obtained from an ongoing longitudinal study in Guangdong, China. A total of 3871 students participated in assessments performed at three time points at one-year assessment intervals. Growth mixture modeling (GMM) was used to estimate trajectory classes for suicidal behaviors, followed by multivariable logistic regression to explore the association between predictive factors and classes.

RESULTS

GMM analyses extracted two distinct trajectories of suicidal behaviors: a low-decreasing group (n = 3669, 94.8 %) and a high-increasing group (n = 202, 5.2 %). Multivariate logistic regression analyses revealed that depressive symptoms, non-suicidal self-injury, hopelessness, and childhood emotional abuse served as risk factors for the high-increasing group, while reasons for living served as protective factors.

CONCLUSIONS

Psychological interventions aimed at reducing the influence of risk factors and bolstering reasons to live may help to decrease the risk of suicide behaviors in college students.

Risk and protective factors for self-harm and suicide in children and adolescents: a systematic review and meta-analysis protocol

INTRODUCTION

Self-harm and suicide are major public health concerns among children and adolescents. Many risk and protective factors for suicide and self-harm have been identified and reported in the literature. However, the capacity of these identified risk and protective factors to guide assessment and management is limited due to their great number. This protocol describes an ongoing systematic review and meta-analysis which aims to examine longitudinal studies of risk factors for self-harm and suicide in children and adolescents, to provide a comparison of the strengths of association of the various risk factors for self-harm and suicide and to shed light on those that require further investigation.

METHODS AND ANALYSIS

We perform a systematic search of the literature using the databases EMBASE, PsycINFO, Medline, CINAHL and HMIC from inception up to 28 October 2020, and the search will be updated before the systematic review publication. Additionally, we will contact experts in the field, including principal investigators whose peer-reviewed publications are included in our systematic review as well as investigators from our extensive research network, and we will search the reference lists of relevant reviews to retrieve any articles that were not identified in our search. We will extract relevant data and present a narrative synthesis and combine the results in meta-analyses where there are sufficient data. We will assess the risk of bias for each study using the Newcastle-Ottawa Scale and present a summary of the quantity and the quality of the evidence for each risk or protective factor.

ETHICS AND DISSEMINATION

Ethical approval will not be sought as this is a systematic review of the literature. Results will be published in mental health journals and presented at conferences focused on suicide prevention.

PROSPERO REGISTRATION NUMBER

CRD42021228212.

A chain multiple mediation model reveals the association between abuse and depression in Chinese adolescents

Background

Depression is a common mental disorder in Chinese adolescents. Identifying its risk factors will facilitate early prevention. As abuse is reported to be a great risk factor of depression, it is necessary to identify factors mediating the relation between abuse and depression.

Objective

This study aims to investigate the association between abuse and depression by investigating the mediating role of academic stress, social anxiety, and generalized anxiety to offer insights for depression prevention.

Participants and setting

We investigated adolescents in urban and rural areas in Wansheng District of Chongqing city in China. This study included a total of 14,108 students from secondary and primary schools, among whom 7,086 were men (50.2%) and 7,022 were women (49.8%). The participants aged from 11 to 17 with an average age of 13.58 (M = 13.58, SD = 1.86).

Methods

A questionnaire survey was conducted among the participants between October and December in 2020. The following questionnaires were adopted: DSM-5 Patient Health Questionnaire for Adolescents, DSM-5 Severity Measure for Generalized Anxiety Disorder, The International Society for Prevention of Child Abuse and Neglect Child Abuse Screening Tool, DSM-5 Severity Measure for Social Anxiety Disorder (Social Phobia), and Study Stress Scale.

Results

The lifetime prevalence of abuse was high in Chinese adolescents. The direct effect value from abuse to depression was 0.05, the total mediating effect value was 0.14, and the overall effect value was 0.19. According to the mediating effect analysis, the direct and indirect effects from abuse to depression were significant, and the mediating effect accounted for 73.68% of the total effect, suggesting that 73.68% of the effects of abuse to depression are mediated by academic stress, social anxiety, and generalized anxiety.

Conclusions

Academic stress, social anxiety and generalized anxiety play a chain multiple mediating role in the association between abuse and depression, which sheds light on the prevention of depression in the future.

High Serum Levels of IL-6 Are Associated with Suicide Attempt but Not with High Lethality Suicide Attempts: A Preliminary Case-Control Study

Suicide attempts are an emerging health problem around the world. Increased levels of IL-6 have been associated with suicidal behavior. Therefore, the aims of this study were to evaluate the serum levels of IL-6 in individuals with suicide attempts and a comparison group and to associate the IL-6 levels with the lethality of the suicide attempt. Additionally, we associated the rs2228145 polymorphism of the IL6R gene with suicide attempts or with the IL-6 serum levels. Suicide attempts and their lethality were evaluated using the Columbia Suicide Severity Rating Scale. The serum concentrations of IL-6 were measured by the ELISA technique in individuals with suicide attempts and then compared to a control group. The rs2228145 polymorphism of the IL6R gene was analyzed by real-time polymerase chain reaction. We found elevated serum levels of IL-6 in the suicide attempt group when compared to the control group (F = 10.37, p = 0.002). However, we found no differences of the IL-6 levels between high and low lethality. The IL6R gene polymorphism rs2479409 was not associated with suicide attempts. Our data suggest that IL-6 serum is increased in individuals with suicide attempts.

Transition from Depression to Suicidal Attempt in Young Adults: The Mediation Effect of Self-Esteem and Interpersonal Needs

BACKGROUND

Depression increases the risk of suicide. Depression and suicide attempts are significantly impacted by low self-esteem and interpersonal needs (i.e., thwarted belongingness (TB) and perceived burdensomeness (PB)). More research is required to clarify how these factors affected the change from depression to suicidal attempts, which would dramatically lower the suicide fatality rate. We sought to examine the mediating roles of self-esteem, TB, and PB in Chinese young adults, since previous research shows that self-esteem has a strong relationship with TB, while TB and PB have strong relationships with suicide attempts.

METHODS

Measures on depression, interpersonal needs, and attempted suicide were completed by a sample of 247 Chinese social media users who had stated suicidal ideation online.

RESULTS

The findings showed that people who attempted suicide had significantly higher levels of TB and PB. Suicidal attempts were also impacted by depression via the mediational chains, which included self-esteem, TB, and PB.

CONCLUSIONS

Our findings might contribute to the expansion of the interpersonal theory of suicide and have an impact on effective suicide prevention.

A risk calculator to predict suicide attempts among individuals with early-onset bipolar disorder

OBJECTIVES

To build a one-year risk calculator (RC) to predict individualized risk for suicide attempt in early-onset bipolar disorder.

METHODS

Youth numbering 394 with bipolar disorder who completed ≥2 follow-up assessments (median follow-up length = 13.1 years) in the longitudinal Course and Outcome of Bipolar Youth (COBY) study were included. Suicide attempt over follow-up was assessed via the A-LIFE Self-Injurious/Suicidal Behavior scale. Predictors from the literature on suicidal behavior in bipolar disorder that are readily assessed in clinical practice were selected and trichotomized as appropriate (presence past 6 months/lifetime history only/no lifetime history). The RC was trained via boosted multinomial classification trees; predictions were calibrated via Platt scaling. Half of the sample was used to train, and the other half to independently test the RC.

RESULTS

There were 249 suicide attempts among 106 individuals. Ten predictors accounted for >90% of the cross-validated relative influence in the model (AUC = 0.82; in order of relative influence): (1) age of mood disorder onset; (2) non-suicidal self-injurious behavior (trichotomized); (3) current age; (4) psychosis (trichotomized); (5) socioeconomic status; (6) most severe depressive symptoms in past 6 months (trichotomized none/subthreshold/threshold); (7) history of suicide attempt (trichotomized); (8) family history of suicidal behavior; (9) substance use disorder (trichotomized); (10) lifetime history of physical/sexual abuse. For all trichotomized variables, presence in the past 6 months reliably predicted higher risk than lifetime history.

CONCLUSIONS

This RC holds promise as a clinical and research tool for prospective identification of individualized high-risk periods for suicide attempt in early-onset bipolar disorder.

Mood and Behaviors of Adolescents With Depression in a Longitudinal Study Before and During the COVID-19 Pandemic

OBJECTIVE

To investigate whether, compared to pre-pandemic levels, depressive and anxiety symptoms in adolescents with depression increased during the pandemic.

METHOD

We used data from National Institute of Mental Health Characterization and Treatment of Depression (NIMH CAT-D) cohort, a longitudinal case-control study that started pre-pandemic. Most of the participants are from the states of Maryland and Virginia in the United States. We compared depressive symptoms (1,820 measurements; 519 measurements pre-pandemic and 1,302 during the pandemic) and anxiety symptoms (1,800 measurements; 508 measurements pre-pandemic and 1,292 ratings during the pandemic) of 166 adolescents (109 girls, 96 adolescents with depression) before and during the pandemic. Data were collected during yearly clinical visits, interim 4-month follow-up visits, inpatient stays, and weekly outpatient sessions, with additional data collection during the pandemic. Pre-pandemic, healthy volunteers (HVs) had a median of 1 depressive and anxiety rating (range, 1-3), and adolescents with depression had a median of 2 ratings (anxiety rating range, 1-25; depressive rating range, 1-26). During the pandemic, HVs had a median of 8 anxiety ratings and 9 depressive ratings (range, 1-13), and adolescents with depression had a median of 7 anxiety and depressive ratings (range, 1-29). We also analyzed adolescent- and parent-reported behaviors in the CoRonavIruS Health Impact Survey (CRISIS), totaling 920 self-reported measures for 164 adolescents (112 girls, 92 adolescents with depression). HVs had a median of 7 surveys (range, 1-8), and adolescents with depression had a median of 5 surveys (range, 1-8).

RESULTS

Pre-pandemic, adolescents with depression had a mean depressive score of 11.16 (95% CI = 10.10, 12.22) and HVs had a mean depressive score of 1.76 (95% CI = 0.40, 3.13), a difference of 9.40 points (95% CI = 7.78, 11.01). During the pandemic, this difference decreased by 22.6% (2.05 points, 95% CI = 0.71, 3.40, p = .003) due to 0.89 points decrease in severity of scores in adolescents with depression (95% CI = 0.08, 1.70, p = .032) and 1.16 points increase in HVs' depressive symptoms (95% CI = 0.10, 2.23, p = .032). Compared to their pre-pandemic levels, adolescents with depression reported overall lower anxiety symptoms during the pandemic. Parent-on-child reports also were consistent with these results.

CONCLUSION

Contrary to our hypothesis, we found that both depressive and anxiety symptoms were lower for adolescents with depression during the pandemic compared to before. In contrast, the depression scores for the HVs were higher during the pandemic relative to their pre-pandemic ratings; these scores remained much lower than those of adolescents with depression.

CLINICAL TRIAL REGISTRATION INFORMATION

Characterization and Treatment of Adolescent Depression; https://clinicaltrials.gov/; NCT03388606.

Potential paths to suicidal ideation and suicide attempts among high-risk women

Although men are more likely to die by suicide, women experience a greater and more rapidly increasing rate of suicidal ideation (SI) and are 3 times more likely to attempt suicide than men. Despite this increased risk, little is known about factors that contribute to SI or suicide attempts (SA) among women. We examined factors associated with SI and SA among women and identified mood-related symptoms that differentiate women who reported attempting suicide from those who did not. Women at elevated risk for depression from across the U.S. (N = 3372; age 18 to 90) completed a survey regarding depression, anxiety, sociodemographic and reproductive status, behavioral/mental health history, and exposure to adversity. Structural equation modeling and logistic regression were used to analyze the data. Variables with the most significant relationships to SI were severity of depression (OR = 5.2, p = 0.000) and perceived stress (OR = 1.18, p = 0.000) while frequency of suicidal thoughts (OR = 3.3, p = 0.000), family history of a depression diagnosis (OR = 1.6, p = 0.000) and exposure to violence (OR = 1.9, p = 0.000) had the strongest association with SA. Childhood abuse/trauma was associated with SA (OR = 1.13, p = 0.000) but not SI. 'Feeling bad about themselves, a failure, or having let themselves or their family down' was the symptom that most clearly differentiated women who attempted suicide from women who reported suicidal ideation but no SA. The salience of childhood abuse and domestic/community violence to women's risk for a suicide attempt reinforces previous findings that these adversities may differentiate suicide risk for women versus men. Continued research is essential to understand varied paths that may lead to suicidal behavior among women, some which appear unrelated to the frequency or intensity of their suicidal thoughts.

Relative deprivation and depressive symptoms among Chinese migrant children: The impacts of self-esteem and belief in a just world

Background

Studies have shown that relative deprivation is a risk factor for depressive symptoms, but the underlying mechanisms are not yet clarified. Thus, this study formulated a moderated mediation model to investigate the mediating role of self-esteem and the moderating role of belief in a just world between relative deprivation and depressive symptoms among rural-to-urban migrant children.

Methods

A sample of 1,076 Chinese migrant children (M _age = 12.25 years, SD = 1.66) completed measurements of relative deprivation, self-esteem, belief in a just world, and depressive symptoms. Furthermore, the mediating mechanism and moderating effect of the study were explored with the SPSS PROCESS macro (Models 4 and 7).

Results

The results showed a significant positive association between relative deprivation and depressive symptoms, with self-esteem partially mediating this association. Moreover, belief in a just world moderated the association between relative deprivation and self-esteem. Namely, the indirect effect of self-esteem was moderated by belief in a just world. Specifically, the mediating effect was stronger for migrant children with higher levels of belief in a just world.

Conclusion

These findings broaden our knowledge of how and when relative deprivation influences depressive symptoms among migrant children. Therefore, appropriate measures should be taken to prevent and manage migrant children' depression and provide them with corresponding guidance. Some measures could be taken by schools and educators to help migrant children with high relative deprivation in improving their self-esteem and belief in a just world, such as self-reference tasks and psychological intervention programs.

Integrating biobehavioral information to predict mood disorder suicide risk

The will to live and the ability to maintain one's well-being are crucial for survival. Yet, almost a million people die by suicide globally each year (Aleman and Denys, 2014), making premature deaths due to suicide a significant public health problem (Saxena et al., 2013). The expression of suicidal behaviors is a complex phenotype with documented biological, psychological, clinical, and sociocultural risk factors (Turecki et al., 2019). From a brain disease perspective, suicide is associated with neuroanatomical, neurophysiological, and neurochemical dysregulations of brain networks involved in integrating and contextualizing cognitive and emotional regulatory behaviors. From a symptom perspective, diagnostic measures of dysregulated mood states like major depressive symptoms are associated with over sixty percent of suicide deaths worldwide (Saxena et al., 2013). This paper reviews the neurobiological and clinical phenotypic correlates for mood dysregulations and suicidal phenotypes. We further propose machine learning approaches to integrate neurobiological measures with dysregulated mood symptoms to elucidate the role of inflammatory processes as neurobiological risk factors for suicide.

Ventral prefrontal serotonin 1A receptor binding: a neural marker of vulnerability for mood disorder and suicidal behavior?

Mood disorders and suicidal behavior have moderate heritability and are associated with altered corticolimbic serotonin 1A receptor (5-HT1A) brain binding. However, it is unclear whether this reflects genetic effects or epigenetic effects of childhood adversity, compensatory mechanisms, or illness stress-related changes. We sought to separate such effects on 5-HT1A binding by examining high familial risk individuals (HR) who have passed through the age of greatest risk for psychopathology onset with and without developing mood disorder or suicidal behavior. PET imaging quantified 5-HT1A binding potential BPND using [11C]CUMI-101 in healthy volunteers (HV, N = 23) and three groups with one or more relatives manifesting early-onset mood disorder and suicide attempt: 1. unaffected HR (N = 23); 2. HR with lifetime mood disorder and no suicide attempt (HR-MOOD, N = 26); and 3. HR-MOOD with previous suicide attempt (HR-MOOD + SA, N = 20). Findings were tested in an independent cohort not selected for family history (HV, MOOD, and MOOD + SA, total N = 185). We tested for regional BPND differences and whether brain-wide patterns distinguished between groups. Low ventral prefrontal 5-HT1A BPND was associated with lifetime mood disorder diagnosis and suicide attempt, but only in subjects with a family history of mood disorder and suicide attempt. Brain-wide 5-HT1A BPND patterns including low ventral prefrontal and mesiotemporal cortical binding distinguished HR-MOOD + SA from HV. A biological endophenotype associated with resilience was not observed. Low ventral prefrontal 5-HT1A BPND may reflect familial mood disorder and suicide-related pathology. Further studies are needed to determine if higher ventral prefrontal 5-HT1A BPND confers resilience, reducing risk of suicidal behavior in the context of familial risk, and thereby offer a potential prevention target.

Genetics and epigenetics of self-injurious thoughts and behaviors: Systematic review of the suicide literature and methodological considerations

Suicide is a multifaceted and poorly understood clinical outcome, and there is an urgent need to advance research on its phenomenology and etiology. Epidemiological studies have demonstrated that suicidal behavior is heritable, suggesting that genetic and epigenetic information may serve as biomarkers for suicide risk. Here we systematically review the literature on genetic and epigenetic alterations observed in phenotypes across the full range of self-injurious thoughts and behaviors (SITB). We included 577 studies focused on genome-wide and epigenome-wide associations, candidate genes (SNP and methylation), noncoding RNAs, and histones. Convergence of specific genes is limited across units of analysis, although pathway-based analyses do indicate nervous system development and function and immunity/inflammation as potential underlying mechanisms of SITB. We provide suggestions for future work on the genetic and epigenetic correlates of SITB with a specific focus on measurement issues.

Rumination as a Mediator of the Association Between Racial Discrimination and Depression Among Black Youth

BACKGROUND

Racial discrimination constitutes a significant risk factor for depressive symptoms among Black youth. Rumination, a maladaptive self-regulatory stress response, is a notable pathway by which racial discrimination contributes to depressive symptoms among racial/ethnic minority adults. Yet, examinations of the mechanistic nature of rumination in the context of racial discrimination among racial/ethnic minority youth remain limited. The present study investigated rumination as a mediator of the association between racial discrimination and depressive symptoms among Black youth.

METHODS

Data for the current study were drawn from baseline questionnaire responses of community recruited Black pre-and-early adolescents (N = 158, 53% female, Mage = 11.50) in the southeast USA participating in an ongoing longitudinal study examining the effects of interpersonal stressors on youth mental health outcomes.

RESULTS

After adjusting for age and gender, mediation analyses revealed a significant indirect effect of racial discrimination on depressive symptoms through rumination, estimate = 0.29, 95% confidence interval [0.12, 0.47]. Racial discrimination was positively associated with rumination (b = .74, SE = .23, p = .001), and rumination, in turn, was positively associated with depressive symptoms (b = .40, SE = .06, p < .001).

CONCLUSION

Consistent with previous research, we found racial discrimination to be directly and indirectly associated with depressive symptoms among Black youth. Findings provide evidence of the cognitive burden of discriminatory experiences and suggest that rumination represents a potential pathway that can be targeted at early developmental stages to reduce the deleterious impact of racism-related stressors.

Associations Between Genetic Risk for Adult Suicide Attempt and Suicidal Behaviors in Young Children in the US

IMPORTANCE

Suicide rates have been increasing among youth in the US. While the heritability of suicide risk is well established, there is limited understanding of how genetic risk is associated with suicidal thoughts and behaviors in young children.

OBJECTIVE

To examine whether genetic susceptibility to suicide attempts (SAs) is associated with suicidal thoughts and behaviors in children.

DESIGN, SETTING, AND PARTICIPANTS

This case-control study examined data from the Adolescent Brain Cognitive Development (ABCD) study, a population-based longitudinal study of 11 878 US children enrolled at age 9 and 10 years from September 2016 to November 2018. Youth reports of suicidal ideation (SI) and SAs were obtained from the Kiddie Schedule for Affective Disorder and Schizophrenia at baseline and 2 subsequent years. After conservative quality control of genotype data, this analysis focused on 4344 unrelated individuals of European ancestry. Data analysis was conducted from November 2020 to February 2022.

MAIN OUTCOMES AND MEASURES

Children's lifetime experiences of SI and SAs were assessed each year from ages 9 to 10 years to ages 11 to 12 years. Polygenic risk scores (PRSs) for SAs were calculated for ABCD study participants based on the largest genome-wide association study of SA cases and controls of European ancestry (total sample n = 518 612).

RESULTS

Of 4344 children of European ancestry (2045 [47.08%] female; mean [SD] age, 9.93 [0.62] years), significant associations were found between children's SA PRSs and their lifetime SAs with the most robust association in the follow-up year 2 (odds ratio, 1.43 [95% CI, 1.18-1.75]; corrected P = 1.85 × 10-3; Nagelkerke pseudo R2 = 1.51%). These associations remained significant after accounting for children's sociodemographic backgrounds, psychopathology symptoms, parental histories of suicide and mental health, and PRSs for major depression and attention-deficit/hyperactivity disorder (likelihood ratio test P &lt; .05). Children's depressive mood and aggressive behavior were the most significant partial mediators of SA genetic risk on SAs (mediation analysis P &lt; 1 × 10-16). Children's behavioral problems, such as attention problems, rule-breaking behavior, and social problems, also partially mediated the association of SA PRSs with SAs (mediation analysis false discover rate &lt; 0.05).

CONCLUSIONS AND RELEVANCE

This study's findings indicate that there may be genetic factors associated with SA risk across the life span and suggest behaviors and conditions through which the risk could be mediated in childhood. Further research is warranted to examine whether incorporating genetic data could improve the identification of children at risk for suicide.