Restrictive Emotionality, Depressive Symptoms, and Suicidal Thoughts and Behaviors Among High School Students

Suicide risk, mentalizing and emotion regulation in adolescents: The role of maternal maladaptive emotion regulation

OBJECTIVE

While a substantial body of research has demonstrated associations between family factors and adolescent suicide risk, little is known about whether maternal mentalizing and emotion regulation play a role in adolescent suicide risk. The objective of this study was to test whether maternal mentalizing and maternal emotion regulation strategies are related to adolescent suicide risk through adolescents' mentalizing ability and emotion regulation strategies.

METHOD

A total of 130 adolescents and young adults (63.6 % female; aged 15-23 years) and their mothers completed a series of self-report questionnaires assessing their suicide risk, anxiety and depression, mentalizing difficulties and cognitive emotion regulation strategies.

RESULTS

Structural equation modeling revealed significant indirect effects between adolescent mentalizing and adolescent suicide risk through adolescent adaptive and maladaptive emotion regulation. The results also showed a moderating effect of adolescent anxiety and depression on the relationships between adaptive emotion regulation strategies and suicide risk in adolescents and young adults. Importantly, maternal maladaptive emotion regulation strategies (i.e., self-blame and catastrophizing) have significant effects on suicidal risk through mentalizing difficulties and adaptive and maladaptive emotion regulation strategies in adolescents and young adults.

CONCLUSIONS

Our findings provide preliminary support for the specific roles of maternal emotion regulation strategies by demonstrating that a higher use of maternal maladaptive emotion regulation strategies are associated with less adolescent mentalizing, which in turn contributes to a higher use of maladaptive strategies and a lower use of adaptive strategies among adolescents, thus increasing the risk of suicide in adolescence and young adulthood.

Text Messaging to Extend School-Based Suicide Prevention: Pilot Randomized Controlled Trial

BACKGROUND

Suicide is the third-leading cause of death among US adolescents aged 10-19 years, and about 10% attempt suicide each year. School-based universal prevention may reduce youth suicidal behavior. Sources of Strength uses a peer leader network diffusion model to promote healthy norms across a school population. A key challenge within schoolwide programs is reaching a large and diverse array of students, especially those less engaged with their peers. Motivated by this challenge, we developed and field-tested Text4Strength-a program of automated text messages targeting help-seeking attitudes and norms, social coping resources, and emotion regulation skills.

OBJECTIVE

This study conducted a pilot randomized controlled trial of Text4Strength in 1 high school as an extension of an ongoing schoolwide program (Sources of Strength), to test its impact on targets that have the potential to reduce suicidal behavior.

METHODS

Students at an upstate New York high school (N=223) received 1-2 text messages per week for 9 weeks, targeting strategies for coping with difficult feelings and experiences through clarifying emotions and focusing on positive affect concepts, awareness, and strengthening of youth-adult relationships; and positive help-seeking norms, skills, and resources. Surveys were administered at baseline, immediately post intervention and 3 months after texting ended. We measured proximal intervention targets (methods of coping during stressful events, ability to make sense of their own emotions, feelings of powerlessness during emotion management and recovery, relations with trusted adults at school, and help-seeking behaviors), symptoms and suicide ideation, and student replies to messages.

RESULTS

No significant effects were observed for any outcome at either follow-up time point. Results showed that if there is a true (but undetected) intervention effect, it is small. Students with fewer friend nominations did not interact any more or less with the text messages. Exploratory moderation analyses observed no interaction between the intervention condition and the number of friends or baseline suicide ideation at any time point.

CONCLUSIONS

In contrast to a promising previous field test, these results suggest that Text4Strength is unlikely to have impacted the outcomes of interest and that undetected moderate or large effects can be ruled out with high confidence. Although motivated by the need to reach more isolated students, students with fewer friends did not engage more or show a greater effect than other participants. This study was conducted in a single high school that was already implementing Sources of Strength, so the bar for showing a distinct effect from texting alone was high. Many further channels for reaching youth through private messaging remain unexplored. Alternative delivery systems should be investigated, such as embedding messaging in gaming chat systems and other media. More sophisticated systems drawing on chatbots may also achieve better outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03145363; https://clinicaltrials.gov/study/NCT03145363.

Nonsuicidal self-injury among Chinese university students during the post-COVID-19 era: analysis of sex differences and the impact of gender role conflict

Background

Global centers of epidemic prevention and control have entered a new stage of normalization, namely, the "post-COVID-19 era." During the post-COVID-19 era, which is characterized by the time period following that with the most serious medical consequences, the psychosocial consequences of the COVID-19 pandemic began to receive worldwide attention, especially the degree of psychological distress it caused.

Aim

This study explored the differential impact of gender role conflict on Chinese university students' engagement in nonsuicidal self-injury (NSSI) as a function of biological sex following the global COVID-19 pandemic.

Methods

Participants were 1,600 university students in northwestern China (M age = 21.3 years; 50.8% women) who completed online measures of demographic variables (including biological sex, gender role conflict, and NSSI engagement).

Results

Women reported significantly more gender role conflicts than men did, while engagement in NSSI was significantly more prevalent among men than women. A total of 262 men reported engaging in at least one NSSI behavior, resulting in a prevalence rate of 33.25%. In comparison, a total of 106 individuals reported engaging in at least one NSSI behavior, resulting in a prevalence rate of 13.05% among women. Gender role conflict was found to significantly predict university students' NSSI engagement, regardless of biological sex.

Conclusion

This is the first empirical study to identify sex differences in both gender role conflict and engagement in NSSI among university students in Northwestern China during the post-COVID-19 era. In addition, the present study is the first to demonstrate how gender role conflict predicts engagement in NSSI across sexes. These findings will inform the literature on gender role conflict and NSSI, particularly the close relationship between gender role conflict and engagement in NSSI among Chinese university students, and they emphasize the need for continued efforts to explore NSSI cross-culturally.

Emotional Modulation of Response Inhibition in Adolescents During Acute Suicidal Crisis: Event-Related Potentials in an Emotional Go/NoGo Task

Objectives. Suicide is the second leading cause of adolescent deaths and may be linked to difficulties with inhibitory and emotional processing. This study assessed the neural correlates of cognitive inhibition during emotional processing in adolescents hospitalized for a suicidal crisis. Methods. Event-related potentials were recorded during an emotional Go/NoGo task in 12 adolescents who attempted suicide and 12 age- and sex-matched healthy controls. Results. Compared to the control group, the suicidal group showed significantly reduced positivity at the time of the P3d (difference waveform reflecting NoGo minus Go trials) in response to happy and neutral, but not sad stimuli. For happy stimuli, this group difference was restricted to the right hemisphere. Further analyses indicated that the suicidal group had a reversed pattern of P3 amplitude in response to inhibition, with lower amplitudes in the NoGo compared to the Go conditions. Suicidal symptoms severity strongly correlated with lower amplitude of the P3d in response to neutral faces. Conclusions. These findings provide more insight into inhibition difficulties in adolescents with acute suicidal risk. Interactions between emotional and inhibition processing should be considered when treating acutely suicidal youths.

The role of alexithymia as a risk factor for self-harm among adolescents in depression - A systematic review

INTRODUCTION

Considering the suggested role of alexithymia in increasing the risk of self-harm, especially when depression is also present, and that rates of self-harm tend to peak in adolescence, the aim of this systematic review was to synthetize the most relevant research studies on this topic and provide an understanding on whether alexithymia can be considered as an important risk factor for non-suicidal self-harm among adolescents with depression.

METHODS

Searches were conducted in PubMed, Web of Science, and PsycINFO, resulting in 290 records. After removal of duplicates, 273 records were left and after reading the titles and abstracts, 231 articles were excluded, leaving 42 articles that were read in full. Of these 42, nine articles were included in this review.

RESULTS

The sample of this review consists of eight case-control studies and one cross-sectional and longitudinal survey. All nine studies concluded that the most important variables associated with self-harming behavior were depression and alexithymia, among all other variables assessed. The self-harming groups showed significantly higher scores on alexithymia (overall and particularly Factor 1- difficulties identifying feelings and differentiating them from bodily sensations), when compared to the control (no self-harming) groups, and the mean depression scores for self-harming groups were significantly higher than those for non-harming groups. All nine studies included in this review shared the limitation of self-reported information.

CONCLUSION

These results indicate that alexithymia is a risk factor for non-suicidal self-harm among adolescents with depression, even when other variables were also inspected, and may be a prevention and therapeutic target in the future.

Suicidal Ideation among Youths at Risk of School Dropout: Impact of Student Demographics, Stressors, and Academic Self-Concept

In the United States, suicidal ideation is an issue for high school-age youths. Research supports that youths who have learning difficulties and who are at risk of high school dropout are at greater risk for suicidal ideation. Although alternative high schools address both student academics and emotional health, they are underused, nonclinical settings for understanding and addressing suicidal ideation. This study aimed to examine the impact of student identity, external stressors, and academic self-concept on suicidal ideation among sexual and ethnic minority and underserved students enrolled in an alternative education public high school. The student sample (N = 103) completed a onetime survey comprised of the Suicidal Ideation Questionnaire-Junior, the Cultural Assessment of Risk of Suicide, the Coddington Life Events Scale for Adolescents, and the Piers Harris 2. Results of hierarchical linear regression indicated that identifying as nonheterosexual and experiencing discrimination were associated with greater student reporting of suicidal ideation. Identifying as Latino and other non-White was associated with lower reporting of suicidal ideation. Controlling for student demographics and external stressors, positive academic self-concept was associated with a lower reporting of suicidal ideation. Findings have future implications for health social work, suicide prevention and intervention, and education policy.

Resilience among students at risk of dropout: Expanding perspectives on youth suicidality in a non-clinical setting

While research supports a strong association between risk of school dropout and suicidality, this youth population remains understudied. This qualitative study addresses this gap by examining self-reported risk and protective factors among 44 alternative high school students who endorsed varying levels of suicidal ideation. Criterion sampling of Suicidal Ideation Questionnaire-JR scores informed student selection for semi-structured interviews. Students were grouped by low, moderate, or high suicidal ideation scores. Transcribed interviews were analyzed using thematic analysis. The findings demonstrate subgroup differences of suicide risk and resiliency among students at risk of dropout and offer points for prevention and intervention. School practitioners can advocate for school-based suicide preventive interventions that are tailored for students who are both at risk of suicide and academic failure.

Searching for a Sense of Place: The Process of How Adolescent Girls Overcome Suicidality

Adolescent suicide is a preventable health problem; however, warning signs are often missed. In this study we developed a grounded theory to explore the process of how adolescent girl suicide attempters escape suicide in a sample of 12 young female adults ages 18-25. Using grounded theory methods of constant comparison, memo-writing, axial, and theoretical coding, searching for a sense of place emerged as the core process encompassing social process stages of: (1) existing in a toxic environment; (2) seeing suicide as the only way out; (3) seeing new ways to escape. Implications for nursing practice, education, and research are discussed.

Depression in High School: Lesbian, Gay, and Bisexual Identity as a Moderator of Sexual Assault

BACKGROUND

Depression continues to be a public health crisis for young adults. For high school students, past research has identified trauma as a significant predictor of depression. Congruent with the theory of cumulative stress, the present study hypothesized that the effect of sexual assault on depression would be stronger among lesbian, gay, and bisexual (LGB) students than among their straight peers.

METHODS

Using the Youth Risk Behavior Survey completed by students attending Duval County Public Schools in Florida (N = 3053), this study used secondary data analysis to conduct 2 regression analyses, one for boys and one for girls.

RESULTS

LGB status was associated with 3-fold increase in the odds of reporting depression for both boys and girls. History of sexual assault was associated with a significant increase in reporting depression. There was also a significant interaction effect between sexual orientation and history of sexual assault among male students only (p < .05). Contrary to the hypothesis, the effect was stronger among straight boys than among LGB boys.

CONCLUSION

Minority students continue to evidence greater risks for depression. Opportunities for systemic changes to address these include training teachers, banning conversion therapy, and implementing comprehensive sex education.

Adolescent Suicide Ideation, Depression and Self-Esteem: Relationships to a New Measure of Gender Role Conflict

Among 15-24 year olds in Ireland, completed suicide was responsible for 4.1 times more male deaths than female deaths in 2014 (World Health Organization [WHO], 2017). Few international research studies have investigated the relationship between masculinity [as assessed by a measure of gender role conflict (GRC)] and suicide ideation, and none have done so with Irish adolescents. Therefore, the purpose of the current study was to investigate the relationships between a new measure of GRC developed specifically for use with Irish adolescents (I-GRCS-A; O'Beaglaoich et al., 2016), and depression, self-esteem, and negative/protective suicide ideation. A sample of 176 adolescent boys (M = 16.9, SD = 0.94) from a non-clinical population participated in the study. Regression analyses and tests of mediation revealed that depression significantly mediated the relationship between GRC and negative suicide ideation, whilst self-esteem and depression significantly mediated the relationship between GRC and positive suicide ideation. Implications and limitations of the current study are outlined and directions for future research are discussed.

Mobile Phone Intervention to Reduce Youth Suicide in Rural Communities: Field Test

BACKGROUND

Suicide is a leading cause of death among 10- to 19-year-olds in the United States, with 5% to 8% attempting suicide each year. Suicide risk rises significantly during early adolescence and is higher in rural and underserved communities. School-based universal prevention programs offer a promising way of reducing suicide by providing strategies for emotion regulation and encouraging help-seeking behaviors and youth-adult connectedness. However, such programs frequently run into difficulties in trying to engage a broad range of students. Text messaging is a dominant medium of communication among youths, and studies show both efficacy and uptake in text messaging interventions aimed at adolescents. Text-based interventions may, thus, offer a means for school-based universal prevention programs to engage adolescents who would otherwise be difficult to reach.

OBJECTIVE

We field tested Text4Strength, an automated, interactive text messaging intervention that seeks to reach a broad range of early adolescents in rural communities. Text4Strength extends Sources of Strength, a peer-led school suicide prevention program, by encouraging emotion regulation, help-seeking behaviors, and youth-adult connectedness in adolescents. The study tested the appeal and feasibility of Text4Strength and its potential to extend universal school-based suicide prevention.

METHODS

We field tested Text4Strength with 42 ninth-grade students. Over 9 weeks, students received 28 interactive message sequences across 9 categories (Sources of Strength introduction, positive friend, mentors, family support, healthy activities, generosity, spirituality, medical access, and emotion regulation strategies). The message sequences included games, requests for advice, questions about students' own experiences, and peer testimonial videos. We measured baseline mental health characteristics, frequency of replies, completion of sequences and video viewing, appeal to students, and their perception of having benefited from the program.

RESULTS

Of the 42 participating students, 38 (91%) responded to at least one sequence and 22 (52%) responded to more than a third of the sequences. The proportion of students who completed multistep sequences they had started ranged from 35% (6/17) to 100% (3/3 to 28/28), with responses dropping off when more than 4 replies were needed. With the exception of spirituality and generosity, each of the content areas generated at least a moderate number of student replies from both boys and girls. Students with higher and lower levels of risk and distress interacted with the sequences at similar rates. Contrary to expectations, few students watched videos. Students viewed the intervention as useful-even those who rarely responded to messages. More than 70% found the texts useful (3 items, n range 29-34) and 90% (36) agreed the program should be repeated.

CONCLUSIONS

Text4Strength offers a potentially engaging way to extend school-based interventions that promote protective factors for suicide. Text4Strength is ready to be revised, based on findings and student feedback from this field test, and rigorously tested for efficacy.

Emotion Reactivity, Comfort Expressing Emotions, and Future Suicidal Ideation in Emerging Adults

OBJECTIVE

Emotion reactivity and difficulties in expressing emotions have been implicated in risk for suicidal behavior. This study examined comfort in expressing emotions (positive vs. negative) and depressive symptoms as mediators of the prospective relation between emotion reactivity and suicidal ideation.

DESIGN

Emerging adults (N = 143; 72% female; 28% White) completed measures of emotion reactivity, comfort expressing emotions, and suicidal ideation at baseline and of depressive symptoms and suicidal ideation 12 months later.

RESULTS

Emotion reactivity predicted suicidal ideation at follow-up through depressive symptoms. Difficulty expressing love-but not happiness, sadness, and anger-partially mediated the relationship between emotion reactivity and suicidal ideation at follow-up before but not after adjusting for baseline ideation.

CONCLUSION

The relation between high emotion reactivity and suicidal ideation may be explained by discomfort in the expression of positive emotions and by depressive symptoms. Promotion of comfort in positive emotion expression may reduce vulnerability to suicidal ideation.

Efficacy of Web-Based Collection of Strength-Based Testimonials for Text Message Extension of Youth Suicide Prevention Program: Randomized Controlled Experiment

Background

Equipping members of a target population to deliver effective public health messaging to peers is an established approach in health promotion. The Sources of Strength program has demonstrated the promise of this approach for “upstream” youth suicide prevention. Text messaging is a well-established medium for promoting behavior change and is the dominant communication medium for youth. In order for peer ‘opinion leader’ programs like Sources of Strength to use scalable, wide-reaching media such as text messaging to spread peer-to-peer messages, they need techniques for assisting peer opinion leaders in creating effective testimonials to engage peers and match program goals. We developed a Web interface, called Stories of Personal Resilience in Managing Emotions (StoryPRIME), which helps peer opinion leaders write effective, short-form messages that can be delivered to the target population in youth suicide prevention program like Sources of Strength.

Objective

To determine the efficacy of StoryPRIME, a Web-based interface for remotely eliciting high school peer leaders, and helping them produce high-quality, personal testimonials for use in a text messaging extension of an evidence-based, peer-led suicide prevention program.

Methods

In a double-blind randomized controlled experiment, 36 high school students wrote testimonials with or without eliciting from the StoryPRIME interface. The interface was created in the context of Sources of Strength–an evidence-based youth suicide prevention program–and 24 ninth graders rated these testimonials on relatability, usefulness/relevance, intrigue, and likability.

Results

Testimonials written with the StoryPRIME interface were rated as more relatable, useful/relevant, intriguing, and likable than testimonials written without StoryPRIME, P=.054.

Conclusions

StoryPRIME is a promising way to elicit high-quality, personal testimonials from youth for prevention programs that draw on members of a target population to spread public health messages.

Can preferences in information processing aid in understanding suicide risk among emerging adults?

The present study evaluated emerging adult (n = 192 college students) preferences in information processing (PIP), defined by the need for affect (NFA) and need for cognition (NFC), as they may be associated with suicide risk. The following were direct indicators of elevated suicide risk: presence of lifetime exposure to suicide (i.e., lifetime yes/no), elevated depressive symptoms, and greater NFA avoidance. Two different interactions resulted in elevated suicide risk: high depressive symptoms and high NFA avoidance, and high NFC and high NFA. Present results concerning PIP hold the potential to inform suicide risk assessment and prevention efforts among young adults.

'Give Me a Reason to Live!' Examining Reasons for Living Across Levels of Suicidality

Scholarly research focusing on social psychological factors (e.g. mental health) and social environmental factors (e.g. childhood trauma) has found these measures to be correlated with suicidality. However, such literature has tended to overlook what may impact one's reasons for living. Using a sample of over 1,200 students from a Canadian university, the goal of the current study is to empirically test, by employing multivariate nested regression models (by levels of suicidal behaviour), known and relative unknown correlates with reasons for living, with a particular focus on strength of religious faith, which is a well-known predictor for suicidality, but less studied as a reason for living. Results show that, among students with serious suicidal ideation and/or a previous suicide attempt, the strongest predictor for student's reasons for living was strength of religious faith. Strength of religious faith has seldom been acknowledged or identified as an important measure in assessing one's reasons to live. These findings have implications for the role of religiosity among suicidality research, especially studies that focus on reasons for living.

ADHD and Suicidal Ideation: The Roles of Emotion Regulation and Depressive Symptoms Among College Students

OBJECTIVE

ADHD appears to increase risk for both depression and suicidal ideation, while ADHD and depression are also associated with emotion regulation deficits. Thus, we evaluated the degree to which depression mediated the association between ADHD and suicidal ideation, as well as the degree to which emotion regulation deficits moderated the association ADHD shared with depression and suicidal ideation in a nonclinical sample.

METHOD

Participants were undergraduate psychology students (N = 627; age: M = 20.23, SD = 1.40; 60% female; 47% European American) who completed an online assessment.

RESULTS

Results indicated that ADHD indirectly increased suicidal ideation through depression. Emotion regulation deficits of accepting negative emotions, emotional awareness, and goal-oriented behavior moderated the indirect effect of ADHD on suicidal ideation.

CONCLUSION

Depression appears to play an important mediating role in suicidal ideation for college students with ADHD, and specific emotion regulation deficits appear to amplify the effects of ADHD on depression and suicidal ideation.

The Measure of Verbally Expressed Emotion: Development and factor structure of a scale designed to assess comfort expressing feelings to others

Emotional expressiveness, which refers to the extent to which people outwardly display their emotions, is associated with various indices of well-being. This study presents findings on the Measure of Verbally Expressed Emotion (MoVEE), an instrument designed to assess comfort expressing both positive and negative emotions to others. A series of studies is described in this paper: 1) pilot study which included 60 undergraduates (69.4% female) from a small college, 2) exploratory factor analytic study which included 835 undergraduates (68% female) from a large university, and 3) confirmatory factor analytic and validity study which included 449 undergraduates (73.3% female). The initial MoVEE included 57 items assessing comfort expressing seven emotional states; the final MoVEE, supported by both an EFA and CFA, is a 19-item measure assessing comfort expressing love, happiness, anger, and sadness. Analyses suggest that the MoVEE is a valid measure that may be a useful tool in clinical settings.

The Association of Interpersonal and Intrapersonal Emotional Experiences with Non-Suicidal Self-Injury in Young Adults

Non-suicidal self-injury (NSSI), the intentional damage to body tissue without the intent to die, is a prevalent public health problem in the U.S. and around the world. The current study sought to identify intrapersonal (emotional reactivity) and interpersonal (emotional expressiveness to others) correlates of NSSI in order to provide insight into how to best tailor prevention and treatment efforts. Four hundred and forty nine college students were surveyed about various psychological characteristics as well as engagement in NSSI. Results indicated that those who have difficulty expressing emotions are at an increased risk for NSSI even after controlling for depressive symptoms and that emotional expressiveness acts as a partial mediator between depression and NSSI. Emotional expressiveness should be a target of treatment among people who engage in NSSI.

Interventions for primary prevention of suicide in university and other post-secondary educational settings

BACKGROUND

Suicide is a leading cause of death among post-secondary students worldwide. Suicidal thoughts and planning are common among post-secondary students. Previous reviews have examined the effectiveness of interventions for symptomatic individuals; however, many students at high risk of suicide are undiagnosed and untreated.

OBJECTIVES

We evaluated the effect on suicide and suicide-related outcomes of primary suicide prevention interventions that targeted students within the post-secondary setting.

SEARCH METHODS

We searched the following sources up to June 2011: Specialised Registers of two Cochrane Groups, Cochrane Central Register of Controlled Trials, and nine other databases, trial registers, conference proceedings, and websites of national and international organizations. We screened reference lists and contacted authors of included studies to identify additional studies. We updated the search in November 2013; we will include these results in the review's next update.

SELECTION CRITERIA

We included studies that tested an intervention for the primary prevention of suicide using a randomized controlled trial (RCT), controlled before-and-after (CBA), controlled interrupted time series (CITS), or interrupted time series (ITS) study design. Interventions targeted students within the post-secondary setting (i.e. college, university, academy, vocational, or any other post-secondary educational institution) without known mental illness, previous suicide attempt or self-harm, or suicidal ideation. Outcomes included suicides, suicide attempts, suicidal ideation, changes in suicide-related knowledge, attitudes and behavior, and availability of means of suicide.

DATA COLLECTION AND ANALYSIS

We used standardized electronic forms for data extraction, risk of bias and quality of evidence determination, and analysis. We estimated standardised mean differences (SMD) with 95% confidence intervals (CIs). We analysed studies by intervention type and study design. We summarized RCT effect sizes using random-effects models meta-analyses; and analysed statistical heterogeneity using the Chi(2) test and I(2) statistic. We described narratively the results from studies that used other study designs.

MAIN RESULTS

Eight studies met inclusion criteria. They were heterogeneous in terms of participants, study designs, and interventions. Five of eight studies had high risk of bias. In 3 RCTs (312 participants), classroom-based didactic and experiential programs increased short-term knowledge of suicide (SMD = 1.51, 95% CI 0.57 to 2.45; moderate quality evidence) and knowledge of suicide prevention (SMD = 0.72, 95% CI 0.36 to 1.07; moderate quality evidence). The effect on suicide prevention self-efficacy in one RCT (152 participants) was uncertain (SMD = 0.20, 95% CI -0.13 to 0.54; low quality evidence). One CBA analysed the effects of an institutional policy that restricted student access to laboratory cyanide and mandated professional assessment for suicidal students. The incidence of student suicide decreased significantly at one university with the policy relative to 11 control universities, 2.00 vs. 8.68 per 100,000 (Z = 5.90; P < 0.05). Four CBAs explored effects of training 'gatekeepers' to recognize and respond to warning signs of emotional crises and suicide risk in students they encountered. The magnitude of effect sizes varied between studies. Gatekeeper training enhanced short-term suicide knowledge in students, peer advisors residing in student accommodation, and faculty and staff, and suicide prevention self-efficacy among peer advisors. There was no evidence of an effect on participants' suicide-related attitudes or behaviors. One CBA found no evidence of effects of gatekeeper training of peer advisors on suicide-related knowledge, self-efficacy, or gatekeeper behaviors measured four to six months after intervention.

AUTHORS' CONCLUSIONS

We found insufficient evidence to support widespread implementation of any programs or policies for primary suicide prevention in post-secondary educational settings. As all evaluated interventions combined primary and secondary prevention components, we were unable to determine the independent effects of primary preventive interventions. Classroom instruction and gatekeeper training increased short-term suicide-related knowledge. We found no studies that tested the effects of classroom instruction on suicidal behavior or long-term outcomes. Limited evidence suggested minimal longer-term effects of gatekeeper training on suicide-related knowledge, while no evidence was found evaluating its effect on suicidal behavior. A policy-based suicide intervention reduced student suicide, but findings have not been replicated. Our findings are limited by the overall low quality of the evidence and the lack of studies from middle- and low-income countries. Rigorously designed studies should test the effects of preventive interventions on important health outcomes, including suicidal ideation and behavior, in varying post-secondary settings.

Validation of the French version of the Suicidal Ideation Questionnaire among adolescents

Teenage suicide is a major public health issue in Western societies, especially in France. An instrument to measure suicidal thoughts in French adolescents and thus identify the teenagers at risk is urgently required. The aim of this study was to validate a French version of the Suicidal Ideation Questionnaire (SIQ) for use with teenagers. Respondents (n=956, age range 14-18.0) completed the SIQ and other convergent measures (self-esteem, psychic morbidity, anxiety, and personality) for three validation steps (general and clinical samples). A confirmatory factor analysis was performed on the SIQ. The study supported a 30-item one-factor model, similar to the original questionnaire, with moderate model fit indices (χ(2)/ddl=3.21; RMSEA=0.05; CFI=0.87; GFI=0.92). Significant correlations (-0.22 to 0.74) were found with convergent measures among general (n=871) and psychiatric samples (n=38). A high internal consistency was found with a reliability coefficient of 0.91. The results confirm the psychometric qualities of the questionnaire for French adolescents.

Non-suicidal self-injury and suicidal behavior: prevalence, co-occurrence, and correlates of suicide among adolescents in Hong Kong

BACKGROUND

Despite increasing concern over the prevalence of non-suicidal self-injury (NSSI) among adolescents, there is debate about its classification as a stand-alone psychiatric diagnosis. This study investigated the patterns, co-occurrence, and correlates of NSSI and other suicidal behaviors among a representative community sample of in-school adolescents.

METHODS

A cross-sectional survey of 2,317 adolescents was conducted. Participants were asked to self-report NSSI, suicidal ideation, suicide attempt, and psychosocial conditions over the past 12 months. Logistic regression and cumulative logit modeling analyses were conducted to investigate the different and similar correlates among these self-harm behaviors.

RESULTS

The age-standardized prevalence rates of NSSI among male and female adolescents were estimated to be 13.4 and 19.7 %, respectively, compared with 11.1 and 10.1 % for male and female suicide attempt. Only a small proportion engaged in NSSI exclusively in the past year. NSSI by burning or reckless and risky behaviors, frequent drinking, and sexual experience were associated with increasing severity level of suicidal behaviors among individuals with NSSI.

CONCLUSIONS

NSSI is prevalent among in-school adolescents in Hong Kong. However, it co-occurs with suicidal ideation and suicide attempt. High lethality of NSSI, frequent drinking habit, and lifetime sexual experience are suggested to be indicators for screening potential suicide attempters among those having NSSI.

Emotion regulation difficulties, youth-adult relationships, and suicide attempts among high school students in underserved communities

To develop and refine interventions to prevent youth suicide, knowledge is needed about specific processes that reduce risk at a population level. Using a cross-sectional design, the present study tested hypotheses regarding associations between self-reported suicide attempts, emotion regulation difficulties, and positive youth-adult relationships among 7,978 high-school students (48.6% male, 49.9% female) in 30 high schools from predominantly rural, low-income communities. 683 students (8.6%) reported a past-year suicide attempt. Emotion regulation difficulties and a lack of trusted adults at home and school were associated with increased risk for making a past-year suicide attempt, above and beyond the effects of depressive symptoms and demographic factors. The association between emotion regulation difficulties and suicide attempts was modestly lower among students who perceived themselves as having higher levels of trusted adults in the family, consistent with a protective effect. Having a trusted adult in the community (outside of school and family) was associated with fewer suicide attempts in models that controlled only for demographic covariates, but not when taking symptoms of depression into account. These findings point to adolescent emotion regulation and relationships with trusted adults as complementary targets for suicide prevention that merit further intervention studies. Reaching these targets in a broad population of adolescents will require new delivery systems and "option rich" (OR) intervention designs.

Associations between suicidal high school students' help-seeking and their attitudes and perceptions of social environment

Suicide is a leading cause of death among adolescents, many of whom fail to disclose suicide concerns to adults who might help. This study examined patterns and predictors of help-seeking behavior among adolescents who seriously considered suicide in the past year. 2,737 students (50.9 % female, 46.9 % male; racial distribution 79.5 % Caucasian, 11.9 % Hispanic/Latino, and 3.6 % Black/African-American) from 12 high schools in rural/underserviced communities were surveyed to assess serious suicide ideation (SI) in the past year, disclosure of SI to adults and peers, attempts to get help, attitudes about help-seeking, perceptions of school engagement, and coping support. Help-seeking was defined as both disclosing SI to an adult and perceiving oneself as seeking help. The relationship between adolescents' help-seeking disclosure and (1) help-seeking attitudes and (2) perceptions of social resources was examined among suicidal help-seeking youth, suicidal non-help-seeking youth, and non-suicidal youth. Of the 381 (14 %) students reporting SI, only 23 % told an adult, 29 % sought adult help, and 15 % did both. Suicidal help-seekers were similar to non-suicidal peers on all measures of help-seeking attitudes and social environment perceptions. Positive attitudes about help-seeking from adults at school, perceptions that adults would respond to suicide concerns, willingness to overcome peer secrecy requests, and greater coping support and engagement with the school were associated with students' increased disclosure of SI and help-seeking. This study supports prevention strategies that change student norms, attitudes and social environments to promote help-seeking among adolescents with SI. Promising intervention targets include increasing students' perceptions of the availability and capability of adults to help them, and strengthening students' understanding of how existing resources can help them cope.