Suicidal thoughts and behaviors in preadolescents: Findings and replication in two population-based samples

Clarifying the relationship between physical injuries and risk for suicide attempt in a Swedish national sample

INTRODUCTION

The Interpersonal-Psychological Theory of Suicide proposes that capability for suicide is acquired through exposure to painful and provocative events (PPEs). Although there is robust evidence for a positive association between aggregate measures of PPEs and risk for suicidal behavior, little is known about the contributions of physical injuries. The present study investigated the relationship between injuries and risk of subsequent suicide attempt (SA).

METHODS

Data were from Swedish population-based registers. All individuals born in Sweden between 1970 and 1990 were included (N = 1,011,725 females and 1,067,709 males). We used Cox regression models to test associations between 10 types of injuries (eye injury; fracture; dislocation/sprain/strain; injury to nerves and spinal cord; injury to blood vessels; intracranial injury; crushing injury; internal injury; traumatic amputation; and other or unspecified injuries) and risk for later SA. Analyses were stratified by sex and adjusted for year of birth and parental education. Additional models tested for differences in the pattern of associations based on age group and genetic liability for SA. In co-relative models, we tested the association between each injury type and risk for SA in relative pairs of varying genetic relatedness to control for unmeasured familial confounders.

RESULTS

All 10 injury types were associated with elevated risk for SA (hazard ratios [HRs] = 1.2-7.0). Associations were stronger in the first year following an injury (HRs = 1.8-7.0), but HRs remained above 1 more than 1 year after injury exposure (HRs = 1.2-2.6). The strength of associations varied across injury type, sex, age, and genetic liability for SA. For example, the magnitude of the association between crushing injury and risk for SA was larger in females than males, whereas other injuries showed a similar pattern of associations across sex. Moreover, there was evidence to support positive additive interaction effects between several injury types and aggregate genetic liability for SA (relative excess risk due to interaction [RERI] = 0.1-0.3), but the majority of these interactions became non-significant or changed direction after accounting for comorbid psychiatric and substance use disorders. In co-relative models, the pattern of associations differed by injury type, such that there was evidence to support a potential causal effect of eye injury, fracture, dislocation/sprain/strain, intracranial injury, and other and unspecified injuries on risk for SA. For the remaining injury types, HRs were not significantly different from 1 in monozygotic twins, which is consistent with confounding by familial factors.

CONCLUSIONS

Injuries are associated with increased risk for subsequent SA, particularly in the first year following an injury. While genetic and familial environmental factors may partly explain these associations, there is also evidence to support a potential causal effect of several injury types on future risk for SA.

Gender Differences in Risks of Suicide and Suicidal Behaviors in the USA: A Narrative Review

PURPOSE OF REVIEW

We review recent research (2018-2023) on gender differences in suicidal behaviors (i.e., suicidal ideations and attempts, death by suicide). We examine research studies in the following areas: developmental period, substance use, and special populations (Veterans, sexual and gender minorities).

RECENT FINDINGS

Novel results were found in these different areas. For example, suicide rates for female youth are increasing at a faster rate relative to male youth. Further, some evidence suggests that heavy alcohol use/binge drinking is a significant and growing risk factor for suicidal behaviors in women. Military service may be a more significant risk factor for suicidal behaviors among male Veterans compared to female Veterans. Additionally, suicide rates are rising for gender minority youth/young adults. Recent research on gender differences in suicide outcomes demonstrates findings that align with previous research, as well as new insights on this important topic.

Nonsuicidal Self-Injury in Preadolescents

OBJECTIVES

There is a dearth of literature on the prevalence and predictors of nonsuicidal self-injury (NSSI) history and onset among preadolescent youth. This gap in the literature is significant given evidence suggesting that NSSI is a robust predictor of negative mental health outcomes, and that early onset NSSI may be associated with a more severe course of self-injurious thoughts and behaviors. This study aimed to evaluate sociodemographic characteristics, psychiatric disorders, and suicidal ideation (SI) in relation to NSSI onset and history in preadolescents.

METHODS

Data were drawn from the Adolescent Brain and Cognitive Development (ABCD) study, which recruited a diverse sample of 11 875 youth aged 9 to 10 years. The primary outcome measures were lifetime history and recent onset of NSSI. Measures included sociodemographics and the K-SADS diagnostic interview assessing psychopathology and SI.

RESULTS

Female sex and identifying as Black were associated with lower odds of lifetime NSSI. Identifying as a sexual minority, having unmarried parents, and a low family income were associated with higher odds of lifetime NSSI. Although depression was most predictive of NSSI history and onset, a range of internalizing and externalizing disorders, greater comorbidity, and SI also were predictive.

CONCLUSIONS

Given that NSSI was associated with a range of mental health disorders and comorbidity, it may be best conceptualized as a transdiagnostic phenomenon. Findings highlight key sociodemographic and diagnostic factors that may help to direct screening efforts in preadolescents, particularly sexual minority status and depression.

Gender identity and expression in relation to depression and anxiety in racial and ethnic minority youth: Evaluations of intersectionality in a population-based study

INTRODUCTION

Transgender and gender non-conforming (TGNC) youth experience higher rates of depression and anxiety. Risk for these outcomes in racial and ethnic minority populations remains unclear. This study aimed to examine disparities in depression and anxiety at the intersection of race and ethnicity and TGNC status in a population-based sample.

METHODS

Data were from the 2019 Minnesota Student Survey. Students (n = 119,648) completed questions about their race, ethnicity, gender identity and expression, depression, and anxiety.

RESULTS

Within racial and ethnic groups, TGNC youth generally had greater risk for depression and anxiety. Significant associations for gender minority identity ranged from ORDepression = 2.25 for Black youth who do not identify as male to ORDepression = 5.08 for non-minority ethnicity youth who do not identify as female. For perceived gender expression in cisgender youth, significant associations ranged from ORDepression = 1.17 for Black youth assigned female at birth and ORAnxiety = 1.17 for other-minority ethnicity youth assigned female at birth to ORDepression = 1.46 for non-minority ethnicity youth assigned female at birth and ORAnxiety = 1.46 for American Indian/Alaskan Native youth assigned male at birth. Within-TGNC-youth comparisons yielded a few racial/ethnic differences relative to White peers. Significant differences ranged from ORAnxiety = 0.53 to ORAnxiety = 1.41 for cisgender females.

LIMITATIONS

The cross-sectional data limits our ability to test causation.

CONCLUSIONS

Multiple-minority youth were not universally at increased risk for depression and anxiety, indicating an intersectional framework is important for understanding risk for these outcomes in TGNC youth. Future research identifying potential risk and protective factors is needed to advance screening and treatment strategies for multiple-minority TGNC youth populations.

The epidemiology of non-suicidal self-injury: lifetime prevalence, sociodemographic and clinical correlates, and treatment use in a nationally representative sample of adults in England

BACKGROUND

Although the clinical importance of non-suicidal self-injury (NSSI) has received increasing recognition, relatively little is known about its epidemiology. The objective of this study was to estimate the lifetime prevalence of NSSI in adults and its association with sociodemographic characteristics, psychiatric disorders, and lifetime treatment for NSSI.

METHODS

A nationally representative face-to-face survey was conducted with 7192 adults aged ≥18 years in England. Respondents were interviewed about engagement in NSSI, psychiatric illness, suicidal thoughts and behavior, and treatment history for this behavior.

RESULTS

The estimated lifetime prevalence rate of NSSI was 4.86%. Younger age, growing up without biological parents in the household, being unmarried, and impoverished backgrounds were associated with NSSI. The majority of respondents with lifetime NSSI (63.82%) had at least one current psychiatric disorder. Most psychiatric conditions were associated with greater odds of lifetime NSSI in multivariate models. NSSI was strongly associated with suicidal ideation and suicide attempts, respectively, even after accounting for psychiatric disorders and sociodemographic covariates. A substantial proportion of respondents with NSSI history (30.92%) have engaged in medically severe self-harm, as indexed by requiring medical attention for this behavior. The majority of respondents with NSSI (56.20%) had not received psychiatric care for this behavior.

CONCLUSIONS

NSSI is prevalent in the general population and associated with considerable psychiatric comorbidity. A high rate of unmet treatment needs is evident among those with this behavior. Those at the greatest lifetime risk for NSSI may also be particularly limited in their resources to cope with this behavior.

Recent research advances in identification and prevention of youth suicide risk

PURPOSE OF THE REVIEW

The rate of youth suicidal behaviors has gradually increased over the last 15 years and continues to grow during the COVID-19 pandemic. This trend burdens mental health services and demands significant developments in risk detection and delivery of interventions to reduce the risk. In this article we outline significant advances and recent findings in youth suicide research that may facilitate strategies for identifying and preventing suicide risk among youth at risk in general and in specific risk groups.

RECENT FINDINGS

The rise in suicide and suicidal behaviors is most likely to affect young people of racial, ethnic, sexual, and gender identity minorities and those living in poverty or experiencing maltreatment. The suicide rate in children is rising and demands special attention. Proximal risk factors for suicidal behavior compared with suicidal ideation have been suggested to identify near-term suicidal risk. Effective and scalable prevention strategies were identified, and the role of new technologies in suicide prevention among youth is to be determined.

SUMMARY

To reach broader suicide prevention in youth and reduce the pressure on mental healthcare, public health approaches and improved service access for minority youth and those living in underserved areas of the world are needed.

Prevalence of suicidal ideation and self-harm behaviours in children aged 12 years and younger: a systematic review and meta-analysis

BACKGROUND

Suicide in children is a pressing public health concern. The increasing number of deaths by suicide and emergency visits for suicidal ideation and self-harm in children might not be fully representative; it is likely that many more children are in distress but do not seek out help. We conducted a systematic review and meta-analysis of existing studies to quantify the prevalence of suicidal ideation and self-harm behaviours among children in the community aged 12 years and younger.

METHODS

In this systematic review and meta-analysis, we searched PsycINFO, MEDLINE, and Web of Science via OVID from database inception to Feb 28, 2022, for articles published in French or English that reported estimates of prevalence of suicidal ideation (including suicide planning) and self-harm behaviours (namely, self-harm, suicide attempts, and non-suicidal self-injury) in children aged 12 years and younger. Reference lists were also searched; case studies, qualitative studies, and health-care visit studies were excluded. The outcomes were suicidal ideation, suicide plan or attempts, and self-harm. We used a random-effects model to calculate the overall pooled prevalence of suicidal ideation and self-harm behaviours for all timeframes combined and for ever versus the past 12 months for suicidal ideation. We used the Joanna Briggs Institute Critical Appraisal tool to evaluate the risk of bias in each study. This study is registered with PROSPERO, CRD42020179041.

FINDINGS

28 articles, encompassing 30 studies overall, met the inclusion criteria, aggregating findings from 98 044 children (of whom 46 980 [50·5%] were girls and 46 136 [49·5%] were boys; six articles did not report sex or gender) aged 6-12 years. The pooled prevalence estimate was 7·5% (95% CI 5·9-9·6) for suicidal ideation from 28 studies and 2·2% (2·0-2·5) for suicide planning from three studies. The pooled prevalence was 1·4% (0·4-4·7) for self-harm from four studies, 1·3% (1·0-1·9) for suicide attempt from six studies, and 21·9% (6·2-54·5) for non-suicidal self-injury from two studies. The prevalence of suicidal ideation was higher in studies that included child-reported outcomes (10·9% [95% CI 8·1-14·5] for child only and 10·4% [6·8-15·5] for child and parent combined) than for parent-only reported outcomes (4·7% [3·4-6·6]; p=0·0004). The prevalence of suicidal ideation and self-harm behaviours was similar in boys and girls (suicidal ideation, 7·9% [95% CI 5·2-12·0] for boys vs 6·4% [3·7-10·7] for girls; self-harm behaviours, 3·5% [1·6-7·2] for boys vs 3·0% [1·4-6·4%] for girls). Detailed ethnicity data were not available. High heterogeneity was identified across estimates (I²>90%), which was not well explained by the characteristics of the studies.

INTERPRETATION

A high number of children in the general population can experience suicidal ideation and self-harm behaviours, thus underlining the need for more research on childhood suicide, including developmentally appropriate preventive strategies, such as youth-nominated support teams or dialectical behavioural therapy.

FUNDING

Canada Research Chair in Youth Mental Health and Suicide Prevention.

Correlates and predictors of the severity of suicidal ideation in adolescence: an examination of brain connectomics and psychosocial characteristics

BACKGROUND

Suicidal ideation (SI) typically emerges during adolescence but is challenging to predict. Given the potentially lethal consequences of SI, it is important to identify neurobiological and psychosocial variables explaining the severity of SI in adolescents.

METHODS

In 106 participants (59 female) recruited from the community, we assessed psychosocial characteristics and obtained resting-state fMRI data in early adolescence (baseline: aged 9-13 years). Across 250 brain regions, we assessed local graph theory-based properties of interconnectedness: local efficiency, eigenvector centrality, nodal degree, within-module z-score, and participation coefficient. Four years later (follow-up: ages 13-19 years), participants self-reported their SI severity. We used least absolute shrinkage and selection operator (LASSO) regressions to identify a linear combination of psychosocial and brain-based variables that best explain the severity of SI symptoms at follow-up. Nested-cross-validation yielded model performance statistics for all LASSO models.

RESULTS

A combination of psychosocial and brain-based variables explained subsequent severity of SI (R² = .55); the strongest was internalizing and externalizing symptom severity at follow-up. Follow-up LASSO regressions of psychosocial-only and brain-based-only variables indicated that psychosocial-only variables explained 55% of the variance in SI severity; in contrast, brain-based-only variables performed worse than the null model.

CONCLUSIONS

A linear combination of baseline and follow-up psychosocial variables best explained the severity of SI. Follow-up analyses indicated that graph theory resting-state metrics did not increase the prediction of the severity of SI in adolescents. Attending to internalizing and externalizing symptoms is important in early adolescence; resting-state connectivity properties other than local graph theory metrics might yield a stronger prediction of the severity of SI.

Prevalence and correlates of suicidal ideation and suicide attempts in preadolescent children: A US population-based study

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