Mental disorders and the risk for the subsequent first suicide attempt: results of a community study on adolescents and young adults

Factors associated with suicide attempt risk in adolescent inpatient psychiatric care: toward a practical model

Suicide is an important social and medical problem, particularly among children and adolescents. The aim of the study was to determine the association of the psychiatric diagnosis and selected psychosocial factors with the risk of suicide attempts among patients of an adolescent psychiatric unit. A retrospective analysis was performed on a database of consecutive N = 1311 patients aged 13-18 years of the adolescent psychiatric ward. A hierarchical logistic regression analysis was performed to assess the predictive value of the main psychiatric diagnosis, for factors selected from the database to determine their influence on the relative risk of a suicide attempt. Primary diagnoses of mood disorders and emotional and behavioral disorders were associated with an increased risk of a current admission after a suicidal attempt, a history of past suicidal attempts and non-suicidal self-harm (NSSI). History of NSSI was associated with a fourfold increase probability of a suicide attempt. Truancy, sexual abuse, heartbreak and frequent conflicts were related to a rise in suicidal attempt risk. Learning difficulties were found to be linked to increased probability of suicidal attempt, but only among women. The current study confirms that the primary diagnosis, NSSI and well-recognized psychosocial factors (including family- and school-related factors) may prove useful in the assessment of suicidal risk among adolescents admitted to a psychiatric ward.

Statistical and artificial intelligence techniques to identify risk factors for suicide in children and adolescents

BACKGROUND

Suicidal Behaviors and Thoughts are a relevant public health issue that includes suicidal ideation, non-suicidal self-harm, attempted suicide, and failed suicides. Since there is a progression of suicidal behaviors, whereby suicide is more likely to be completed if there have already been previous behaviors or attempts to harm oneself, WHO has highlighted the need to detect early predictors of such suicidal behaviors, which can help identify individuals at risk, plan prevention strategies and implement specific therapeutic interventions, particularly in young people, thus reducing the number of deaths. This retrospective observational study aimed to identify early predictors of suicidal risk in 237 inpatients admitted for Suicidal Behaviors and Thoughts at Child and Adolescent Psychiatry Emergency Unit of the Meyer Children's Hospital, Florence, Italy.

METHODS

The study was subdivided into three phases: data collection, statistical analysis, and neural network. For each patient, we collected epidemiological and psychopathological data. We stratified the inpatients into two groups: "suicidal volition patients" and "suicidal motivation patients."

RESULTS

The hospitalization rate for suicidal behaviors and thoughts showed a growing trend from 2016 to 2020 (27.69 to 45.28%). Under 12 years of age, diagnosis of disruptive, impulse-control and conduct disorder, previous specialist care, history of attempted suicide, and intoxication as methods of suicide were statistically correlated to an increased risk of suicidal behaviors. Artificial intelligence, with an accuracy of 86.7%, confirmed these risk factors.

LIMITATIONS

The most important limitation of the study is its retrospective nature.

CONCLUSIONS

Our study identifies new early predictors of suicidal risk: age less than 12, diagnosis of disruptive, impulse-control and conduct disorder. In addition, suicidal volition behavior emerges as an important and underestimated risk factor. The use of artificial intelligence methods could be supporting the clinician in assessing suicidal risk.

Does an app designed to reduce repetitive negative thinking decrease depression and anxiety in young people? (RETHINK): a randomized controlled prevention trial

BACKGROUND

The first onset of common mental health disorders, such as mood and anxiety disorders, mostly lies in adolescence or young adulthood. Hence, effective and scalable prevention programs for this age group are urgently needed. Interventions focusing on repetitive negative thinking (RNT) appear especially promising as RNT is an important transdiagnostic process involved in the development of depression and anxiety disorders. First clinical trials indeed show positive effects of preventative interventions targeting RNT on adult as well as adolescent mental health. Self-help interventions that can be delivered via a mobile phone app may have the advantage of being highly scalable, thus facilitating prevention on a large scale. This trial aims to investigate whether an app-based RNT-focused intervention can reduce depressive and anxiety symptoms in young people at risk for mental health disorders.

METHODS

The trial will be conducted in a sample (planned N = 351) of individuals aged 16-22 years with elevated levels of RNT but no current depression or anxiety disorder. In a randomized controlled between-subjects design, two versions of the app-based self-help intervention will be compared to a waiting list control condition. The full RNT-focused intervention encompasses a variety of RNT-reducing strategies, whereas the concreteness training intervention focuses on only one of these strategies, i.e., concrete thinking. The primary outcome (depressive symptoms) and secondary outcomes (anxiety symptoms and RNT) will be measured at pre-intervention, post-intervention (6 weeks after pre-intervention), and follow-up (18 weeks after pre-intervention).

DISCUSSION

This trial aims to find out whether targeting RNT via an app is an effective and feasible way of preventing depression and anxiety disorders in adolescents. Since app-based interventions are highly scalable, this trial might contribute to tackling challenges related to the increasing rates of mental health disorders among young people.

TRIAL REGISTRATION

https://www.drks.de , DRKS00027384. Registered on 21 February 2022-prospectively registered.

Sex-based variations of prefrontal structure and longitudinal symptoms in pediatric posttraumatic stress disorder

BACKGROUND

Pediatric posttraumatic stress disorder (pPTSD) is more than three times as likely to develop in trauma-exposed female youth than males. Despite the staggering sex differences in the prevalence rates of pPTSD and symptom expression, relatively little is known about the underlying biomarkers of these sex-based variations in pPTSD as compared to typically development.

METHODS

The Youth PTSD study recruited 97 youth, ages of 7 and 18, to undergo comprehensive clinical assessments and T1-weighted MRI to evaluate the extent to which sex can explain PTSD-related variations in brain structure. Whole-brain VBM as well as whole-brain estimates of cortical thickness and surface area were analyzed to identify group-by-sex interactions. Finally, we tested whether current or future symptom severity was predictive of regions exhibiting sex-based variations.

RESULTS

Clinically, females with PTSD were significantly more likely to report exposure to and higher severity of interpersonal violence and symptoms of hyperarousal. Sex and PTSD status were predictive of gray matter across the lateral prefrontal cortex (PFC), including the ventrolateral PFC and frontal pole, where increased volume and surface area was found in PTSD females as compared to PTSD males. Interestingly, the ventrolateral prefrontal cortex and frontal pole were negatively predictive of symptoms 1 year later in only males with PTSD.

CONCLUSIONS

Together, these results establish that youth with PTSD exhibit sex-based variations in clinical and trauma characteristics and prefrontal cortical structure relative to normative development. This work demonstrates the importance of examining the role that sex may play in the behavioral and neurobiological presentation of pPTSD.

Suicide spectrum among young people during the COVID-19 pandemic: A systematic review and meta-analysis

BACKGROUND

There are concerns that suicidal behaviors are arising among adolescents. The COVID-19 pandemic could have worsened the picture, however, studies on this topic reported contrasting results. This work aimed to summarise findings from the worldwide emerging literature on the rates of suicidality among young people during the COVID-19 pandemic.

METHODS

A systematic review and meta-analysis were performed, searching five electronic databases for studies published from January 1, 2020 until July 27, 2022. Studies reporting rates for each of the three considered outcomes (suicide, suicidal behaviors, and suicidal ideation) among young people under 19 years old during the COVID-19 pandemic were included. Random-effects meta-analyses were conducted, and the intra-study risk of bias was assessed. When pre-COVID-19 data were available, incidence rate ratio (IRR) and prevalence ratio (PR) estimates were calculated between the two periods. All the analyses were performed according to the setting explored: general population, emergency department (ED), and psychiatric services. The review protocol was registered on PROSPERO (CRD42022308014).

FINDINGS

Forty-seven observational studies were selected for more than 65 million subjects. The results of the meta-analysis showed a pooled annual incidence rate of suicides of 4.9 cases/100,000 during 2020, accounting for a non-statistically significant increase of 10% compared to 2019 (IRR 1.10, 95% CI: 0.94-1.29). The suicidal behaviors pooled prevalence during the COVID-19 pandemic was higher in the psychiatric setting (25%; 95% CI: 17-36%) than in the general population (3%; 1-13%) and ED (1%; 0-9%). The pooled rate of suicidal ideation was 17% in the general population (11-25%), 36% in psychiatric setting (20-56%) and 2% in ED (0-12%). The heterogeneity level was over 97% for both outcomes in all settings considered. The comparison between before and during COVID-19 periods highlighted a non-statistically significant upward trend in suicidal behaviors among the general population and in ED setting. The only significant increase was found for suicidal ideation in psychiatric setting among studies conducted in 2021 (PR 1.15; 95% CI: 1.04-1.27), not observed exploring 2020 alone.

INTERPRETATION

During the pandemic, suicide spectrum issues seemed to follow the known pattern described in previous studies, with higher rates of suicidal ideation than of suicidal behaviors and suicide events. Governments and other stakeholders should be mindful that youth may have unique risks at the outset of large disasters like the COVID-19 pandemic and proactive steps are necessary to address the needs of youth to mitigate those risks.

FUNDING

The present study was funded by the University of Torino (CHAL_RILO_21_01).

Social anxiety in adolescents and young adults from the general population: an epidemiological characterization of fear and avoidance in different social situations

Social Anxiety Disorder (SAD) and, more generally, social fears are common in young people. Although avoidance behaviors are known to be an important maintaining factor of social anxiety, little is known about the severity and occurrence of avoidance behaviors in young people from the general population, hampering approaches for early identification and intervention. Symptoms, syndromes, and diagnoses of DSM-5 mental disorders including SAD were assessed in a random population-based sample of 14-21-year-olds (n = 1,180) from Dresden, Germany, in 2015/2016 using a standardized diagnostic interview (DIA-X-5/D-CIDI). An adapted version of the Liebowitz Social Anxiety Scale was used to ascertain the extent of social fears and avoidance. Diagnostic criteria for lifetime SAD were met by n = 82 participants, resulting in a weighted lifetime prevalence of 6.6%. Social anxiety was predominantly reported for test situations and when speaking or performing in front of others. Avoidance was most prevalent in the latter situations. On average, anxiety and avoidance first occurred at ages 11 and 12, respectively, with avoidance occurring in most cases either at about the same age as anxiety or slightly later. In the total sample, lifetime prevalence for most DSM-5 disorders increased with the severity of social anxiety and avoidance. Results underline the need for preventive or early intervention efforts especially regarding test anxiety and fear and avoidance of speaking in front of others. These situations are particularly relevant in youth. Avoidance behaviors may also be discussed as diagnostic marker for early case identification.

Gaming My Way to Recovery: A Systematic Scoping Review of Digital Game Interventions for Young People's Mental Health Treatment and Promotion

Nearly all young people use the internet daily. Many youth with mental health concerns, especially since the Covid-19 pandemic, are using this route to seek help, whether through digital mental health treatment, illness prevention tools, or supports for mental wellbeing. Videogames also have wide appeal among young people, including those who receive mental health services. This review identifies the literature on videogame interventions for young people, ages 12-29, and maps the data on game use by those with mental health and substance use problems, focusing on evidence for the capacity of games to support treatment in youth mental health services; how stakeholders are involved in developing or evaluating games; and any potential harms and ethical remedies identified. A systematic scoping review methodology was used to identify and assess relevant studies. A search of multiple databases identified a total of 8,733 articles. They were screened, and 49 studies testing 32 digital games retained. An adapted stepped care model, including four levels, or steps, based on illness manifestation and severity, was used as a conceptual framework for organizing target populations, mental health conditions and corresponding digital games, and study results. The 49 selected studies included: 10 studies (20.4%) on mental health promotion/prevention or education for undiagnosed youth (Step 0: 7 games); 6 studies (12.2%) on at-risk groups or suspected mental problems (Step 1: 5 games); 24 studies (49.0%) on mild to moderate mental conditions (Steps 2-3: 16 games); and 9 studies (18.4%) focused on severe and complex mental conditions (Step 4: 7 games). Two interventions were played by youth at more than one level of illness severity: the SPARX game (Steps 1, 2-3, 4) and Dojo (Steps 2-3 and 4), bringing the total game count to 35 with these repetitions. Findings support the potential integration of digital games in youth services based on study outcomes, user satisfaction, relatively high program retention rates and the potential usefulness of most games for mental health treatment or promotion/prevention. Most studies included stakeholder feedback, and involvement ratings were very high for seven games. Potential harms were not addressed in this body of research. This review provides an important initial repository and evaluation of videogames for use in clinical settings concerned with youth mental health.

Association study of Catechol-O-Methyltransferase (COMT) rs4680 Val158Met gene polymorphism and suicide attempt in Mexican adolescents with major depressive disorder

AIM

We analyzed the association between SLC6A4, DRD2, COMT and MAOA genes and suicide attempt (SA) in Mexican adolescent patients with major depressive disorder (MDD).

METHODS

The sample included 197 adolescents (127 females and 70 males) with principal diagnosis of MDD. Among them, 63 patients had SA at least once and 134 had not SA. The mean age of patients with and without SA was 15 ± 1.4 and 14 ± 1.5 years, respectively. We analyzed the genotype and allele distribution between patients with and without SA of SLC6A4 (5HTTLPR/rs25531), DRD2 (rs6275), COMT (rs4680), and MAOA (uVNTR).

RESULTS

We did not find genotype or allele association between SA and SLC6A4 (χ²=0.67, p = 0.71; χ²=0.07, p = 0.77, respectively), DRD2 (χ²=0.05, p = 0.97; χ²=0.003, p = 0.95), and MAOA (females: χ²=0.86, p = 0.64; χ²=0, p = 1/males: χ²=0.008, p = 0.92) genes. However, there were differences in genotype frequencies of COMT/rs4680 between patients with SA and without SA (χ²=11.17, p = 0.003). Also, we observed a high frequency of Met158 allele showing an increased risk of having presented at least one SA (χ²=10.6, p = 0.001; OR = 1.43; 95% CI, 1.17-1.74).

CONCLUSIONS

Our findings showed an association between low activity genotype and allele of Val158Met polymorphism of COMT gene and SA in Mexican adolescents with MDD.

Evaluating Adolescent Substance Use and Suicide in the Pediatric Emergency Department

OBJECTIVES

This study evaluates the relationship between substance use and impairment and current suicidal thoughts or behaviors in adolescent patients screened in a pediatric emergency department (ED).

METHODS

Data were collected between June 2013 and February 2018 from adolescent patients who presented to a single, urban, pediatric ED. Adolescents completed a computerized, self-administered assessment that evaluates depression, suicide, posttraumatic stress, violence, traumatic exposure, bullying, and substance use. Assessments are administered as standard care to all ED patients aged 14 to 18 years. We used binary logistic regression to estimate the odds of reporting current suicidal thoughts or behaviors associated with patient demographics (ie, age, sex, and race), substance use in the past month, and substance-related impairment.

RESULTS

A total of 11,623 adolescent patients (65.4% female and 52.9% African American) completed the assessment. Participants were, on average, 15.7 years old (SD = 1.27). Younger age (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.74-0.84) and substance use impairment (OR, 0.44; 95% CI, 0.33-0.58) decreased the odds of reporting current suicidal thoughts or behaviors, whereas male sex (OR, 1.51; 95% CI, 1.28-1.79) and those with past-month substance use (OR, 1.85; 95% CI, 1.51-2.26) increased the odds.

CONCLUSIONS

Recent substance use and male sex are associated with a higher likelihood of adolescents reporting current suicidal thoughts or behaviors during an ED visit. Standardized screening during pediatric ED visits may allow for more efficient evaluation of patients in higher-risk groups.

The Association Between Problem Gambling and Suicidal Ideations and Attempts: A Case Control Study in the General Swedish Population

The association between problem gambling and suicidal behaviours is well established in treatment seeking populations, but less explored among sub-clinical problem gamblers in the general population. The aim of this study was to examine the association between problem gambling (including moderate risk gambling) and suicidal ideations/suicide attempts, in the general Swedish population. Another aim was to compare problem gamblers with and without suicide ideation/attempts. A case-control study nested in the Swelogs cohort was used. Both ideations and attempts were about twice as frequent among the cases compared to the controls. After controlling for socio-economic status and life-time mental health problems, suicidal ideation, but not attempts, remained significantly higher among the cases compared to the controls. The largest difference between attempters and non-attempters were on payment defaults and illicit drug abuse, whereas depression yielded the largest difference between ideators and non-ideators. Problem gambling severity (PGSI 8+) resulted in the smallest difference, compared to the other variables, between attempters and non-attempters. Even though no conclusion regarding the casual relationship can be drawn in this type of study, it seems like sub-clinical levels of problem gambling might have an impact on suicidal ideations whereas for suicide attempts to occur, other factors need to be present. In addition to mental health issues, financial difficulties may be such factors.

Recommendations for perioperative care of adolescents at risk for suicide

Suicide is one of the leading causes of death for the adolescent population, and as such, should be considered when adolescents have any contact with the healthcare system, including perioperative appointments. Although some surgical facilities screen patients with a history of suicide attempt or severe mental health conditions, many adolescents who have died by suicide do not have official mental health diagnoses or history of previous suicide attempt. Because of the impact surgery can have on mental health, each adolescent should be screened for suicide risk during pre-surgical consult appointments to assess suicide risk and take proper precautions, as needed. Suicide screening should be implemented as part of the focused assessment prior to surgery to more comprehensively combat the rising suicide rates of adolescents. This paper provides recommendations to direct care of adolescent surgical patients at risk for suicide.

Treatment Refractory Internalizing Behaviour Across Disorders: An Aetiological Model for Severe Emotion Dysregulation in Adolescence

Auto-aggressive behaviour, especially treatment refractory suicidality in adolescents with psychiatric disorders, may be challenging to clinicians. In search of therapeutic possibilities, we have integrated current opinions regarding causality and interdependency of suicidality and auto-aggressive behaviour across disorders within the HiTOP framework. We propose a developmental model regarding these unsettling behaviours in youths that may help to guide future directions for research and interventions. We argue that the interdependent development of biologic factors, attachment, moral reasoning and emotion regulation in an overprotective environment may lead to social anxiety and later during development to emotion dysregulation and severe internalizing behaviour disorders. To optimize treatment efficacy for both internalizing and externalizing behaviour, we emphasize the importance transdiagnostic interventions, such as addressing non-compliance, restoration of trust between parents and their child, and limitation of avoidance behaviour. These may be seen as higher order interventions within the HiTOP framework.

Neurobehavioral correlates of impaired emotion recognition in pediatric PTSD

Despite broad evidence suggesting that adversity-exposed youth experience an impaired ability to recognize emotion in others, the underlying biological mechanisms remains elusive. This study uses a multimethod approach to target the neurological substrates of this phenomenon in a well-phenotyped sample of youth meeting diagnostic criteria for posttraumatic stress disorder (PTSD). Twenty-one PTSD-afflicted youth and 23 typically developing (TD) controls completed clinical interview schedules, an emotion recognition task with eye-tracking, and an implicit emotion processing task during functional magnetic resonance imaging )fMRI). PTSD was associated with decreased accuracy in identification of angry, disgust, and neutral faces as compared to TD youth. Of note, these impairments occurred despite the normal deployment of visual attention in youth with PTSD relative to TD youth. Correlation with a related fMRI task revealed a group by accuracy interaction for amygdala-hippocampus functional connectivity (FC) for angry expressions, where TD youth showed a positive relationship between anger accuracy and amygdala-hippocampus FC; this relationship was reversed in youth with PTSD. These findings are a novel characterization of impaired threat recognition within a well-phenotyped population of severe pediatric PTSD. Further, the differential amygdala-hippocampus FC identified in youth with PTSD may imply aberrant efficiency of emotional contextualization circuits.

Posttraumatic Stress Disorder and the Developing Adolescent Brain

Posttraumatic stress disorder (PTSD) in adolescents is common and debilitating. In contrast to adult PTSD, relatively little is known about the neurobiology of adolescent PTSD, nor about how current treatments may alter adolescent neurodevelopment to allow recovery from PTSD. Improving our understanding of biological mechanisms of adolescent PTSD, taken in the context of neurodevelopment, is crucial for developing novel and personalized treatment approaches. In this review, we highlight prevailing constructs of PTSD and current findings on these domains in adolescent PTSD. Notably, little data exist in adolescent PTSD for prominent adult PTSD constructs, including threat learning and attentional threat bias. Most work to date has examined general threat processing, emotion regulation, and their neural substrates. These studies suggest that adolescent PTSD, while phenomenologically similar to adult PTSD, shows unique neurodevelopmental substrates that may impair recovery but could also be targeted in the context of adolescent neuroplasticity to improve outcomes. Both cross-sectional and longitudinal data suggest abnormal frontolimbic development compared with typically developing youths, a pattern that may differ from resilient youths. Whether current treatments such as trauma-focused psychotherapy engage these targets and restore healthy neurodevelopment remains an open question. We end our review by highlighting emerging areas and knowledge gaps that could be addressed to better characterize the biology underlying adolescent PTSD. Emerging studies in computational modeling of decision making, caregiver-related transmission of traumatic stress, and other areas may offer new targets that could harness adolescent neurobehavioral plasticity to improve resilience and recovery for some of our most vulnerable youths.

Suicidal Ideation Mediates the Relationship Between Affect and Suicide Attempt in Adolescents

Suicide, as one of the leading causes of death for the adolescent population, both in Chile and globally, remains a complex and elusive phenomenon. This research studies the association between positive and negative affect in relation with suicidal ideation and suicidal attempt, given that affectivity is a fundamental basis on which people make evaluations on their satisfaction with life. First, it examines the reliability, structure, and validity of Watson's positive and negative affect scale (PANAS) scale in a representative random sample of Chilean high school students (N = 4,568). The scale evidences strong reliability coefficients and a confirmatory factor analysis, excluding one positive (excited) and one negative (nervous) item. The scale shows a satisfactory goodness of fit. Secondly, it investigates the association of PANAS positive and negative affect scores with suicidal ideation as well as reported attempt in adolescents, controlling for the potential effect of age and sex (N = 420 high school students). Low positive and high negative affect, but not sex and age, show a significant association with suicidal ideation. Suicidal ideation totally mediates the association of affect with suicide attempt, as expected. Results are discussed regarding prevention and it considers how positive and negative affect can be relevant as indicators for prevention and treatment using widely available technology.

Suicidality in Childhood and Adolescence

BACKGROUND

The suicide of minors in Germany is rare in absolute numbers: there were only 212 suicides among persons aged 10 to 20 in Germany in 2017. Nonetheless, in school surveys, 36.4-39.4% of those surveyed reported suicidal ideation, and 6.5-9% reported suicide attempts. Suicide among children and adolescents is thus a clinically and societally relevant problem.

METHODS

This review is based on pertinent articles retrieved by a selective literature search in the PubMed and PsycInfo databases (April 2019) employing the search terms "suicidality," "suicidal*," and "suicide," and on further information from several textbooks (1991-2017).

RESULTS

In children and adolescents with a mental illness, the risk of suicide is higher by a factor of 3 to 12. Mobbing experiences increase the suicide risk as well (odds ratio [OR] = 2.21, p <0.05). Non-suicidal self-injurious behavior (NSSB) is also a risk factor for both suicidal ideation (OR = 2.95) and suicide attempts (hazard ratio [HR] = 2.00). Intoxication with medications is the most common method of attempted suicide (67.7%). Most suicides are preceded by early warning signs. Psychiatric hospitalization is indicated for children and adolescents who are in acute danger of doing harm to themselves. Specific types of treatment, family-centered methods in particular, have been found to lessen the frequency of suicidal ideation and suicide attempts. The administration of antidepressant drugs to children and adolescents is controversial, as there is evidence of increased suicidality (but not mortality) for single medications. Antidepressant drugs should not, however, be withheld for this reason, if indicated. The prerequisite in all cases is close observation.

CONCLUSION

To prevent suicide and improve outcomes, risk factors for suicide must be considered, and the indications for primary and secondary preventive and therapeutic measures must be established. Online therapeutic modalities may become more widely used in the near future, particularly among young patients, who are well versed in the use of the Internet.

Prospective prediction of suicide attempts in community adolescents and young adults, using regression methods and machine learning

BACKGROUND

The use of machine learning (ML) algorithms to study suicidality has recently been recommended. Our aim was to explore whether ML approaches have the potential to improve the prediction of suicide attempt (SA) risk. Using the epidemiological multiwave prospective-longitudinal Early Developmental Stages of Psychopathology (EDSP) data set, we compared four algorithms-logistic regression, lasso, ridge, and random forest-in predicting a future SA in a community sample of adolescents and young adults.

METHODS

The EDSP Study prospectively assessed, over the course of 10 years, adolescents and young adults aged 14-24 years at baseline. Of 3021 subjects, 2797 were eligible for prospective analyses because they participated in at least one of the three follow-up assessments. Sixteen baseline predictors, all selected a priori from the literature, were used to predict follow-up SAs. Model performance was assessed using repeated nested 10-fold cross-validation. As the main measure of predictive performance we used the area under the curve (AUC).

RESULTS

The mean AUCs of the four predictive models, logistic regression, lasso, ridge, and random forest, were 0.828, 0.826, 0.829, and 0.824, respectively.

CONCLUSIONS

Based on our comparison, each algorithm performed equally well in distinguishing between a future SA case and a non-SA case in community adolescents and young adults. When choosing an algorithm, different considerations, however, such as ease of implementation, might in some instances lead to one algorithm being prioritized over another. Further research and replication studies are required in this regard.

Specific traumatic events elevate the risk of a suicide attempt in a 10-year longitudinal community study on adolescents and young adults

Traumatic events (TEs) have been associated with suicide attempts (SAs). However, the empirical status of some TEs is inconclusive. This also concerns community adolescents and young adults, known to be a high-risk group for SAs. We examined associations between (a) a range of prior TEs (physical attack, rape/sexual abuse, serious accident, and witnessing somebody else experiencing a TE) and a subsequent SA, and (b) the number of prior TEs and an SA, and (c) we estimated attributable proportions of SAs, in relation to each TE. Over a 10-year period, the Early Developmental Stages of Psychopathology (EDSP) study prospectively assessed community members, aged 14-24 years at baseline. Starting with 3021 subjects, each individual was assessed up to four times. Assessment was based on the Munich-Composite International Diagnostic Interview. Temporal associations were estimated using the Cox model with time-dependent covariates. Attributable proportions were based on the results of the Cox models. All four TEs elevated the risk for a subsequent SA, adjusting for confounders. Highest risk was found for the combined TE rape/sexual abuse. Results showed that 56-90% of SAs could be attributed to TEs in the exposed group; on the population level, attributable proportions ranged between 6.9% and 23.5%. Different TEs have been shown to elevate the risk of an SA in a young community sample. Our results suggest that both health professionals and health policy decision-makers consider specific TEs and the number of prior TEs as risk factors for SAs.

Prevalence, Onset, and Course of Suicidal Behavior Among Adolescents and Young Adults in Germany

Importance

Suicidal behavior is a leading cause of death among adolescents and young adults. In light of the ideation-to-action framework, the delineation of frequency and temporal characteristics of such behavior during this developmental period is crucial.

Objectives

To provide lifetime and 12-month prevalence estimates of suicidal behavior, including ideation, plan, and attempt, in adolescents and young adults of the general population, and to provide information about age at onset, temporal characteristics of suicidal behavior, including duration (number of years between onset and last occurrence) and frequency (number of episodes), and transition patterns across suicidal behaviors.

Design, Setting, and Participants

A cross-sectional epidemiological study was conducted in a random community sample of 1180 adolescents and young adults aged 14 to 21 years assessed in 2015 to 2016 in Dresden, Germany. Data analysis was performed from October 2018 to March 2019.

Main Outcomes and Measures

Lifetime and 12-month suicidal behavior (ideation, plan, and attempt) were assessed with a standardized diagnostic interview (Munich-Composite International Diagnostic Interview) by trained clinical interviewers. The onset, frequency, and duration of suicidal behavior were assessed by questionnaire.

Results

Of the 1180 participants (495 male [weighted percentage, 51.7%]; mean [SD] age, 17.9 [2.3] years), 130 participants (10.7%; 95% CI, 9.0%-12.8%), 65 participants (5.0%; 95% CI, 3.9%-6.5%), and 41 participants (3.4%; 95% CI, 2.4%-4.7%) reported lifetime suicidal ideation, plan, and attempt, respectively. Any lifetime suicidal behavior was reported by 138 participants (11.5%; 95% CI, 9.7%-13.7%). Age-specific cumulative incidence estimates indicated an increase in suicidal behavior during adolescence, starting at age 10 years (<1%), increasing slightly until the age of 12 years (2.2%), and then increasing sharply thereafter until age 20 years (13.5%). There were different patterns among female and male participants for ideation, plan, and attempt, with an overall higher incidence among female participants for ideation (hazard ratio, 1.51; 95% CI, 1.02-2.22; P = .04), for plan (hazard ratio, 3.31; 95% CI, 1.72-6.36; P < .001), and, among those older than 14 years, for attempt (hazard ratio, 3.07; 95% CI, 1.11-8.49; P = .03). Of those with suicidal ideation, 66.0% reported persistent or recurrent ideation over more than 1 year with 75.0% reporting more than 1 episode. Of the participants with lifetime suicidal ideation, 47.0% reported a suicide plan and 23.9% reported a suicide attempt. The transition to suicide plan or attempt occurred mainly in the year of onset of suicidal ideation or plan; of those who transitioned, 74.9% transitioned from ideation to plan, 71.2% transitioned from ideation to attempt, and 85.4% transitioned from plan to attempt in the same year.

Conclusions and Relevance

There is an urgent public health need for timely identification of suicidal behavior in adolescents and young adults to terminate persistent or recurrent suicidal tendencies and to interrupt the ideation-to-action transition.

Commentary: Paediatric post-traumatic stress disorder from a neurodevelopmental network perspective: reflections on Weems et al. (2019)

Paediatric post-traumatic stress disorder (PTSD) is an incredibly heterogeneous and syndromic disorder that likely has a myriad of underlying neurobiological mechanisms at play. The disorder is even more complicated in youth, given that the expression of illness interacts with ongoing developmental processes. In their review in this issue, Weems and colleagues call for broader network-based approaches for studying the development and expression of PTSD in youth. In this commentary, I highlight some of the important knowledge gaps raised by Weems et al. and propose ways in which future studies may leverage network-based approaches for eventual translation into clinical care. Key concepts include the use of network-based approaches for understanding the emergence and maintenance of PTSD symptom architecture over development, identification of resilient and vulnerable patterns of symptom and brain network architecture following trauma, and consideration of how divergence between biological (e.g. brain) and chronological may inform our understanding of resilient and vulnerable patterns over development. Importantly, advancing and translating this work to clinical care will require larger, prospective studies assessing youth as early in development as possible, and integrating information across multiple research groups and sites.