Mediators between adverse childhood experiences and suicidality

Childhood adversity and suicidal ideation in older Korean adults: unraveling the mediating mechanisms of mental health, physical health, and social relationships

BACKGROUND

Suicide rates in older adults are much higher than those in younger age groups. Given the rapid increase in the proportion of older adults in Korea and the high suicide rate of this age group, it is worth investigating the mechanism of suicidal ideation for older adults. Generally, adverse childhood experiences are positively associated with suicidal ideation; however, it is not fully understood what mediating relationships are linked to the association between these experiences and current suicidal ideation.

METHODS

The data from 685 older Korean adults were analyzed utilizing logistic regression, path analyses, and structural equation modeling. Based on our theoretical background and the empirical findings of previous research, we examined three separate models with mental health, physical health, and social relationship mediators. After that, we tested a combined model including all mediators. We also tested another combined model with mediation via mental health moderated by physical health and social relationships.

RESULTS

The univariate logistic regression results indicated that childhood adversity was positively associated with suicidal ideation in older adults. However, multivariate logistic regression results demonstrated that the direct effect of childhood adversity became nonsignificant after accounting all variables. Three path models presented significant mediation by depression and social support in the association between childhood adversity and suicidal ideation. However, combined structural equation models demonstrated that only mediation by a latent variable of mental health problems was statistically significant. Social relationships moderated the path from mental health problems to suicidal ideation.

CONCLUSIONS

Despite several limitations, this study has clinical implications for the development of effective strategies to mitigate suicidal ideation. In particular, effectively screening the exposure to adverse childhood experiences, early identification and treatment of depressive symptoms can play a crucial role in weakening the association between childhood adversity and suicidal ideation in older adults.

Adverse childhood experiences, gender, and suicidality among Florida high school students: Examining intervening mechanisms

BACKGROUND

Adverse childhood experiences (ACEs) represent a key risk factor for suicidal thoughts and behaviors among adolescents. However, the intervening mechanisms linking ACEs and suicidality, and whether such processes vary by gender, remain underexplored.

OBJECTIVE

The present study examines whether the relationships between ACEs and the likelihood of experiencing suicidal thoughts and attempting suicide are indirect through depressive symptoms and low self-control. This study also investigates whether these direct and indirect paths might be moderated by gender.

PARTICIPANTS AND SETTING

The analyses make use of data on a statewide representative sample of students enrolled in public high schools in Florida (N = 23,078) from the 2022 Florida Youth Substance Abuse Survey (FYSAS).

METHODS

Generalized structural equation modeling (GSEM) was used to estimate the direct and indirect effects of ACEs on the likelihood of suicidal thoughts and attempting suicide. The indirect effects were assessed using bootstrapping, and between-gender differences in the coefficients were tested.

RESULTS

ACEs has direct associations with depressive symptoms, low self-control, and both suicidality outcomes. The effects of ACEs on suicidal thoughts are indirect through both depressive symptoms and low self-control, and the effects of ACEs on suicide attempts are indirect through depressive symptoms. Limited gender differences in these pathways emerge.

CONCLUSIONS

For male and female youth, ACEs are associated with heightened depression symptoms and reduced self-control, and both of these factors partially explain the previously established relationship between ACEs and suicidality.

Associations between early child adversity and lifetime suicide attempts among gender diverse individuals: A moderated mediation

BACKGROUND

This study examines the effect of adverse childhood experiences (ACEs) on lifetime suicide attempts (LSA) across five gender subgroups (i.e., transgender men, transgender women, transgender non-binary, cisgender men and cisgender women).

OBJECTIVE

To examine (1) the prevalence of LSA across gender identity subgroups; (2) whether the association between ACEs and LSA is moderated by gender identity subgroup; (3) depressive symptoms, alcohol use disorder, social support, and social well-being as mechanisms linking ACEs with LSA; and (4) the moderating role of gender identity on the four putative mediators.

PARTICIPANTS AND SETTINGS

We used nationally representative data from a population-based survey of N = 1368 transgender and cisgender individuals collected between 2016 and 2019.

METHODS

Structural equation modeling was used to explore the indirect effect of depressive symptoms on the relation between ACEs and LSA, and the moderating impact of gender identity.

RESULTS

LSA was significantly more prevalent among transgender respondents (cisgender man = 5 %; cisgender woman = 9 %; transgender man = 42 %; transgender woman = 33 %; transgender non-binary = 37 %; p < 0.001). Individuals with more ACEs had a greater risk of engaging in LSA regardless of gender identity; however, moderation results showed that the impact of each additional ACE on LSA was stronger for individuals with transgender identities: the likelihood of engaging in LSA was statistically similar for transgender men with no ACEs and cisgender men with all 8 ACEs. Indirect effects of ACEs on LSA via depressive symptoms were also observed, and the mediating effect was moderated by gender identity.

CONCLUSIONS

By examining the mechanisms linking childhood adversity to LSA, this study demonstrates that not all ACEs impact gender minority subgroups equally.

Brief Report: The Association of Adverse Childhood Experiences and Suicide-Related Behaviors Among 10th-Grade Secondary School Students

The association between adverse childhood experiences and suicide-related behaviors (SRB) of adolescents has been widely studied in Western high-income countries, but not yet in Latin America. The aim of this study was to determine this association and to explore a dose-response relationship between adverse childhood experiences and SRB in Chile. We conducted a cross-sectional survey to assess adverse childhood experiences up to 1 year prior to the survey and SRB (suicide ideation and attempts) in a sample of secondary school students. Multilevel and multivariable logistic regressions were run with SRB as dependent and adverse childhood experiences as independent variables, adjusted by self-esteem, general mental health, friend and parental support, and the age at onset of cannabis and alcohol use. We included 7,458 adolescents (48.7% girls), mean age = 16.0 (SD = 0.7), and found a prevalence of 78.1% for at least one adverse childhood experience. The 6-month prevalence of suicidal ideation was 18.1% (95% confidence interval [CI]: 17.2%-19.0%), and the prevalence of suicide attempts was 5.0% (95% CI: 4.6-5.6). Among all adverse childhood experiences, only sexual abuse was a risk factor for both SRB. We also found an independent effect of the total number of adverse childhood experiences on suicidal ideation (p < .001) and on suicide attempts (p < .001). Additionally, ages at onset of alcohol and cannabis use were associated with suicidal ideation and suicidal attempts, respectively. This is the first study exploring the influence of adverse childhood experiences on suicide-related behaviors in adolescents from Latin America.HIGHLIGHTSSexual abuse is associated with suicidal ideation and suicide attempts in 10th-grade secondary school studentsThere is a dose-response effect between adverse childhood experiences and suicide-related behaviorAges at onset of alcohol and cannabis use were associated with suicidal ideation and suicidal attempts, respectively.

Is the end in the beginning? Child maltreatment increases the risk of non-suicidal self-injury and suicide attempts through impaired personality functioning

BACKGROUND

Child maltreatment is a risk factor for a range of mental disorders later in life, including dangerous self-harm and suicide attempts. A better understanding of the mechanisms underlying this association can inform prevention and intervention.

OBJECTIVE

To investigate personality functioning as a potential mediator of the association of childhood abuse and neglect and self-harm and suicide attempts in the general population.

PARTICIPANTS AND SETTING

Data were drawn from a representative German population sample (N = 2510).

METHODS

Participants filled out the Childhood Trauma Questionnaire (CTQ), OPD Structure Questionnaire (OPD-SQS), and items of the Self-Injurious Thoughts and Behaviors Interview (SITBI). In structural equation models, we operationalized impaired personality functioning as the mediator between childhood abuse and neglect and self-harm.

RESULTS

Individuals with a history of self-harm (combining suicide attempts, N = 47, and non-suicidal self-injury, N = 83) reported more childhood abuse and neglect (d = 1.39, p < .001) and greater impairments in personality functioning (d = 1.64, p < .001) than the rest of the population. The indirect effect via personality functioning accounted for 48.8 % of the total effect of childhood abuse and neglect on self-harm. In more differentiated analyses, emotional abuse showed the strongest association with self-harm. Only physical and sexual abuse had direct effects.

CONCLUSIONS

The results specify the relationship between child maltreatment and self-harm by demonstrating that it is partly mediated by basic functions of personality assessed using a dimensional measure. These abilities constitute modifiable risk factors that can be addressed by psychotherapy.

Pathways to Suicidal Behavior in Children and Adolescents: Examination of Child Maltreatment and Post-Traumatic Symptoms

Suicide in youth exacts significant personal and community costs. Thus, it is important to understand predisposing risk factors. Experiencing adverse childhood experiences (ACEs), such as child maltreatment (CM-ACE), and the presence of post-traumatic stress disorder has been identified as a risk factor of suicidal behaviors among adults. Theoretical models of suicide suggest that the presence of painful experiences such as CM-ACEs increase the risk of suicidal behaviors. The relation between child maltreatment, post-traumatic stress symptom clusters (PTSS) and suicidal behaviors has not been explicitly examined among youth. The present study examined the relations between CM-ACEs, PTSS clusters, and suicidal behaviors in a clinical population of children. Children, male, ages 6 to 14, enrolled in a residential treatment program completed self-report measures to evaluate variables of interest. Path analyses revealed statistically significant direct effects of CM-ACEs and PTSS clusters on suicidal behaviors. Significant total indirect effects and marginally significant individual indirect effects of intrusion and avoidance symptoms were observed for the relation between CM-ACEs and suicidal behavior. Findings suggest that symptoms associated with specific PTSS clusters might help explain the relation between CM-ACEs and suicidal behavior, and therefore, present important implications for clinical practice and future research.

Impulsivity as a mediator between childhood maltreatment and suicidal behavior: A systematic review and meta-analysis

Childhood maltreatment is a known risk factor for the development of suicidal behavior. Possible mediators of the association between childhood maltreatment and suicide have been analyzed. Some studies have considered impulsivity as one of these mediators, but there are no previous reviews on this topic. We, therefore, present a systematic review and mediation meta-analysis of the literature summarizing the evidence on impulsivity as a mediator of the relationship between childhood maltreatment and lifetime suicidal behavior. This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The review was registered in the PROSPERO database. We searched PubMed, PsycINFO, WebOfScience, and EMBASE databases up to February 2021 to identify studies exploring the association between childhood maltreatment and suicide through impulsivity. Fourteen articles met the selection criteria and were included in the review. Seven articles could be included in the mediation meta-analysis. Impulsivity was a significant mediator of the relationship between childhood maltreatment and suicidal behavior in ten of the fourteen included studies. This result was confirmed using mediation meta-analysis (β = .06, 95% CI 0.03-0.10). Studies suggest that exposure to traumatic situations in childhood affects the proper neurobiological, cognitive, and affective development of individuals. This may increase impulsivity, which in turn would be related to an increased risk of suicide. The effects of childhood maltreatment and impulsivity may be both therapeutic targets of interest to reduce suicide rates.

Profiles of adverse childhood experiences and protective resources on high-risk behaviors and physical and mental disorders: Findings from a national survey

BACKGROUND

Adverse childhood experiences (ACE) vary across culture and their heterogenous impact on health outcomes is understudied. The present population-based study determined latent classes of adverse childhood experiences, examined socio-demographic variations between identified classes, and elucidated the interactions between class membership and protective resources (i.e., positive mental health and perceived social support) on high-risk behaviors (i.e., smoking, binge drinking, and suicidality), chronic physical disorders, and mental disorders.

METHODS

A total of 4441 adult Singapore residents were recruited from the community. Lifetime mental disorders and suicidality were assessed on structured clinical interviews by trained interviewers, while chronic physical disorders, smoking, binge drinking, ACE, perceived social support, and positive mental health were self-reported.

RESULTS

Latent class analysis identified three distinct profiles; a multiple adversities class endorsing elevated levels of abuse and violence (6.1%), an emotionally neglected and bullied class (7.6%), and a low adversities class (86.2%). The multiple adversities class was associated with younger age, female gender, lower education status, more high-risk behaviors (e.g. binge drinking and suicidality), and physical/mental disorders. A three-way interaction was observed between ACE profiles, social support, and positive mental health on suicidality; high social support and positive mental health reduced the risk of suicidality in the multiple adversities class.

LIMITATIONS

Results may not be generalizable beyond the Singapore population due to cultural factors.

CONCLUSIONS

Clinical assessment should adopt a person-centered approach to identify profiles of ACE and determine their interactions with protective resources on high-risk behaviors and physical/mental disorders; patient-tailored treatment may subsequently build upon these profiles.

Trauma Exposure and Suicidality in a Pediatric Emergency Psychiatric Population

OBJECTIVES

The increasing rates of depression and suicidality in children and adolescents are reflected in the increasing number of mental health-related visits to emergency departments. Despite the high rates of traumatic exposure experienced by high-acuity children and adolescents and a known link to suicidal ideation, the systematic review of trauma history is not a consistent part of emergency department assessments for suicide ideation or attempt. In the present study, we examined the prevalence of suicidality as well as traumatic exposures in children and adolescents presenting to a dedicated pediatric psychiatric emergency department.

METHODS

Suicide ideation, suicide attempts, and trauma exposure history were identified through a retrospective chart review of youth (n = 861) who presented to a dedicated child psychiatric emergency department during a 1-year period. Bivariate analyses comparing demographic and trauma history for children with and without suicidality and a multivariable logistic regression were performed.

RESULTS

Childhood adversity was common, with 52% of youth reporting at least one type of trauma exposure. Emotional abuse, physical abuse, and sexual abuse/assault were associated with suicidality. Any trauma exposure and the total number of different trauma exposures were associated with reported suicide attempt. After adjusting for sociodemographic characteristics, children who reported a history of emotional abuse had 3.2-fold increased odds of attempted suicide. Children who reported a history of being a victim of bullying had 1.9-fold increased odds of current suicidal ideation.

CONCLUSIONS

Traumatic experiences were common in youth presenting with suicidality. Traumatic experiences are frequently underrecognized in treatment settings because they are not part of routine evaluations and are often overlooked when trauma-related symptoms are not the presenting problem. Addressing traumatic experiences underlying depression and suicidal ideation is a necessary step in effective treatment. Emergency departments need to implement routine screening for traumatic exposures in children presenting with suicidal ideation or attempt.

Study Protocol for an Ecological Momentary Assessment Study: TempRes "Temporal Variability of Risk and Resilience Factors for Suicidal Ideation"

Suicide prevention is an important public mental health issue that can be significantly brought forward by recent advances in psychological research methods and assessment. The project "TempRes" aims to harness the power of Ecological Momentary Assessment (EMA) to investigate the transdiagnostic risk and resilience factors associated with suicidal ideation drawn from the most recent research in suicide prevention and personality assessment. Participants will comprise the general population (planned: N = 100) and a risk group (patients currently in psychosomatic or psychiatric treatment) (planned: N = 50). After a comprehensive baseline assessment, they will complete up to ten short assessments per day over the course of 10 days at roughly equidistant intervals. In detail, the project examines the interplay of biography (previous suicidal behavior, experiences of childhood maltreatment), individual differences (level of personality functioning), and time-varying factors (entrapment, loneliness, mood) with respect to the emergence and fluctuation of suicidal ideation. There are two main research foci: First, the project will provide an operationalization and empirical verification of a core assumption of the integrated motivational-volitional model of suicide (IMV model). It will test whether the interaction of the time-varying predictors entrapment with loneliness (as a motivational moderator) explains reports of suicidal ideation over time. Second, it will be the first to examine personality functioning (a transdiagnostic, psychodynamically grounded conceptualization of vulnerability to psychological crises over the life span) as a time-invariant predictor of suicidal ideation assessed within an intensive longitudinal study design. The main analyses will be built on linear mixed models. The overarching aim of the project is to gain a better understanding of the psychological dynamics underlying suicidal ideation in different populations by bringing together concepts from different theoretical traditions. This will inform prevention efforts geared toward the general public as well as intervention in clinical populations.

The mediating role of internalizing and externalizing symptoms in the relationship between childhood trauma and suicidality among adolescents: a structural equation model

BACKGROUND

The objective of this study is to investigate the direct and indirect effects of childhood trauma, internalizing symptoms, and externalizing symptoms on suicidality among adolescents, thereby establishing a structural equation model.

METHODS

The present study uses a cross-sectional descriptive design. Among 147 adolescents aged 12-17, 93 outpatients diagnosed with major depressive disorder and 54 controls were included in the study. They completed the Early Trauma Inventory Self-Report (Short Form) and Columbia Suicidality Severity Rating Scale. Their parents completed the Child Behavior Checklist. Analyses were performed using Pearson's correlation and structural equation modelling.

RESULTS

Childhood trauma had both direct and indirect effects, via internalizing symptoms and externalizing symptoms, on suicidality. Internalizing symptoms had a direct effect on suicidality. Meanwhile, externalizing symptoms were not directly associated with suicidality, but indirectly associated via internalizing symptoms.

CONCLUSIONS

Findings provide in-depth understanding of the mediating role of internalizing symptoms and externalizing symptoms in the relationship between childhood trauma and suicidality, suggesting that the therapeutic interventions for both internalizing symptoms and externalizing symptoms may be important to prevent suicide in adolescents with childhood trauma.

Exploring the mediating role of methamphetamine use in the relationship between adverse childhood experiences and attempted suicide

OBJECTIVE

Methamphetamine (METH) use and adverse childhood experiences (ACEs) has been associated with an increased risk of suicidal behaviour. However, whether METH use underlies the risk of suicide attributable to ACEs is unknown and warrants investigation to inform preventive interventions. In this study, we examined the mediating role of METH use in the relationship between attempted suicide and ACEs.

METHOD

METH users recruited from a mandatory detoxification center (n = 346) and healthy controls (n = 342) both completed a survey related to 9 types of ACE, which was based the Family Health Questionnaire. A lifetime history of attempted suicide was obtained using the Chinese version of the Composite International Diagnostic Interview. We conducted a bootstrapped mediation analysis to examine the mediating effect of METH use on the association between ACEs and attempted suicide.

RESULTS

Female gender, METH use, and having multiple (≥3) ACEs were associated with an increased risk of attempted suicide. A dose-response relationship between the number of ACEs and suicide rate was observed among individuals with METH use. METH use significantly mediated the association between ACEs and attempted suicide in those with multiple (2 and 3 ACEs respectively with proportion mediated 0.16 and 0.42) and specific types of ACEs (physical abuse, witnessing maternal battering, household substance abuse, sexual abuse, and parental separation with proportion mediated 0.25, 0.35, 0.38, 0.48, 0.47 respectively).

CONCLUSION

Our study is the first to demonstrate that METH use partially mediates the association between ACEs and attempted suicide. Addressing METH use in people with ACEs could reduce their suicide risk.

Childhood adversity, suicidality, and non-suicidal self-injury among children and adolescents admitted to emergency departments

PURPOSE

This population-based study explored the associations between childhood adversity and admission to emergency departments (EDs) with non-suicidal self-injury (NSSI) and with a suicide attempt.

METHODS

A nationally representative cross-sectional sample of 5-17-year-olds admitted to EDs (N = 143,113,677) from 2006 to 2015 was utilized to assess the associations between childhood adversities, NSSIs, and suicide attempts.

RESULTS

ED admissions with NSSI and admissions with a suicide attempt were associated with greater odds of exposure to individual childhood adversities (aORs: 1.34 to 5.86; aORs: 2.37 to 15.69, respectively). ED admissions with a suicide attempt were associated with greater odds of exposure to childhood adversities that might be perceived as less extreme or harmful (separation or divorce aOR: 15.69) than other adversities (death of a family member aOR: 13.38; history of physical abuse aOR: 9.56) as well as greater odds of exposure to three or more childhood adversities (aOR: 20.98).

CONCLUSION

Early detection of childhood adversities is important for identifying potential risk factors for self-harm. ED admission data can provide population-level surveillance to aid in these efforts and lead to more targeted and effective interventions aimed at reducing the negative effects of toxic stress that can result from exposure to childhood adversities.

Childhood maltreatment, psychiatric symptoms, and suicidal thoughts among adolescents receiving substance use treatment services

INTRODUCTION

Childhood maltreatment experiences are associated with future suicidal thoughts and suicide attempts, yet the roles of specific psychiatric symptoms mediating this relation remain to be clarified. To clarify these relations, we tested a model incorporating multiple forms of childhood maltreatment (sexual abuse, physical punishment, emotional neglect), past year psychiatric disorder symptoms during adolescence (anxiety, mood, and conduct disorders) and recent suicidal thoughts.

METHODS

We administered structured interviews to 394 adolescents receiving outpatient substance use treatment services in the Southeastern United States (280 males; Mage = 16.33; SDage = 1.15). Structural equation models (SEMs) were used to evaluate the degree to which relations between childhood maltreatment and suicidal thoughts were mediated by specific past-year psychiatric symptoms.

RESULTS

Mood disorder symptoms significantly mediated the relation between neglect/negative home environment and suicidal thoughts. This path of influence did not vary by gender.

CONCLUSIONS

Childhood maltreatment and subsequent psychopathology influence suicidal thoughts among adolescents receiving substance use treatment services. The findings of the present study have implications for the adaptation and delivery of substance use treatment services to adolescents to enhance treatment engagement and outcomes.

Adolescent Inpatients with Depression: Comparison to Inpatients without Depression and to Peers without Psychiatric Disorders

Background:

Family background, social support and psychological characteristics are known to be associated with depression in adolescence, but scientific data in complex, naturalistic settings are scarce.

Objective:

To investigate the characteristics of adolescent psychiatric inpatients with depressive disorders compared to peers without psychiatric disorders and to adolescent psychiatric inpatients without depression.

Methods:

The study population of 206 inpatients (13-17 years old) and 203 age and gendermatched non-referred adolescents was evaluated using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL) interview, and clinical interview and clinical records when available. Structured self-reports provided information on family background, defense styles, self-image and perceived social support. We compared firstly subjects with current depressive disorders (n=120) to subjects without any psychiatric disorder (n=159) and secondly within the inpatient population, those with depressive disorders (n=117) to those with any other psychiatric diagnoses (n=89).

Results:

Current depressive disorders were characterized by worse self-image, less mature defenses and less perceived social support particularly from the family. Adversities in the family were more prevalent in subjects with depression compared to subjects without any psychiatric diagnosis, while among inpatients, no significant differences were observed. Psychiatric comorbidity was common in all inpatients, whereas suicidality was more prevalent among inpatients with depression.

Conclusions:

Negative self-image, less mature defense style and low perceived social support particularly from the family were characteristics of depression in adolescents.

Adverse adolescence experiences, feeling lonely across life stages and loneliness in adulthood

Loneliness is a mental health issue emerging over the life course. This study examines the latent structure of adult loneliness in a non-Western society and its association with adverse adolescence experiences (AAEs) as well as feeling lonely during middle school, high school, and college. Method: A cohort sample living in Northern Taiwan (N = 2,289) was analyzed from adolescence to adulthood. The de Jong Gierveld Loneliness Scale operationalized loneliness by a three-cluster model to present the latent structure of loneliness: emotional, serious emotional, and severe emotional/social loners. AAEs (e.g., abuse, neglect, and dysfunctional family) were measured by seven items. Multivariate multinomial logistic regression models were used to explore the longitudinal effects of AAEs and feeling lonely reported during middle school, high school, and college on adult loneliness. Results: AAEs and feeling lonely during adolescence were significantly associated with serious emotional loneliness and severe emotional/social loneliness during adulthood, even after adjusting for the individual’s characteristics. Attendance at a 4-year college was associated with decreased odds of serious emotional loneliness and severe emotional/social loneliness. Conclusions: Adults with AAEs and feelings of loneliness over life stages are more likely to report loneliness in the emotional and social domains.

Developmental pathways from child maltreatment to adolescent suicide-related behaviors: The internalizing and externalizing comorbidity hypothesis

Child maltreatment is a robust risk factor for suicidal ideation and behaviors during adolescence. Elevations in internalizing and externalizing symptomology have been identified as two distinct developmental pathways linking child maltreatment and adolescent risk for suicide. However, recent research suggests that the co-occurrence of internalizing and externalizing symptomology may form a distinct etiological pathway for adolescent risk behaviors. Using the Longitudinal Studies on Child Abuse and Neglect (LONGSCAN) sample (N = 1,314), the present study employed a person-centered approach to identify patterns of concurrent change in internalizing and externalizing psychopathology over five time points from early childhood to adolescence in relation to previous experiences of child maltreatment and subsequent suicidal ideation and behaviors. Results indicated four distinct bivariate externalizing and internalizing growth trajectories. Group membership in a heightened comorbid internalizing and externalizing symptom trajectory mediated the association between childhood abuse and adolescent suicidal ideation and suicidal behaviors. These findings suggest that the concurrent development of externalizing and internalizing symptoms in childhood and adolescence may constitute a unique developmental trajectory that confers risk for suicide-related outcomes.