Association between sleep duration, suicidal ideation, and suicidal attempts among Chinese adolescents: The moderating role of depressive symptoms

Sleep and circadian rhythms in adolescents with attempted suicide

Sleep and circadian rhythm disorders are very common in adolescents and have been linked to suicidal ideation. However, little is known about adolescent sleep before a suicide attempt (SA). The objectives of this study were to compare the sleep of adolescents aged 13 to 18 over a period of 4 weeks before a SA compared to a non-SA group, then to analyze the association between sleep, support social and well-being based on information from validated questionnaires. In 2015, 250 adolescents were included, 55 were recruited the day after a SA in French hospitals (before SA evaluations were retrospective). Logistic regression analyzes showed that during school days, bedtime was equivalent in both groups, but sleep onset latency was significantly longer in SA (86 min vs. 52 min, p = 0.016), and wake-up time was earlier (6 h 22 vs. 6 h 47, p = 0.002), resulting in a shorter total sleep time of 44 min (OR = 0.76, CI 95% [0.61-0.93]) the month preceding SA. Adolescents with longer sleep time performed better on perceived psychological well-being (p = 0.005), relationship with parents (p = 0.011) and school environment (p < 0.001). Results indicate a significant change in the quantity and quality of adolescents' subjective sleep in the 4 weeks preceding SA requiring objective measures to study the predictive properties of sleep in SA.

Sleep disturbance and suicidal ideation mediated by psychotic-like experiences in adolescents: a two-wave longitudinal study

STUDY OBJECTIVES

Sleep disturbance may cause suicidal ideation (SI). This study aimed to examine their co-occurrence rate among adolescents and investigate whether psychotic-like experiences (PLEs) mediate this association.

METHODS

A total of 17 722 Chinese adolescents were included in this two-wave longitudinal study. The baseline survey (time 1, T1) was conducted between April 21 and May 12, 2021, and the follow-up survey (time 2, T2) was implemented between December 17 and 26, 2021. At T1, participants completed questionnaires to assess their sleep disturbance, sleep duration, PLEs, SI, depressive symptoms, and sociodemographic characteristics. At T2, participants reported their PLEs, SI, and negative life events.

RESULTS

The SI prevalence decreased from 20.2% (T1) to 18.4% (T2). Participants with SI showed significantly higher prevalence of sleep disturbance and short sleep duration compared to those without SI. Baseline sleep disturbance and short sleep duration were both associated with the increased risk of SI 6 months later. These longitudinal links were mediated by PLEs, independent of baseline covariates and negative life events.

CONCLUSIONS

These findings provide a novel insight into the mechanism linking sleep problems and suicidality, and stress the significance of assessing and addressing sleep problems and PLEs for adolescent suicide prevention and intervention.

When Night Falls Fast: Sleep and Suicidal Behavior Among Adolescents and Young Adults

Sleep disturbances have been linked to suicidal ideation and behaviors in adolescents. Specifically, insomnia and nightmares are associated with current suicide risk and predict future ideation. Associations between hypersomnia, sleep apnea, and suicide remain inconclusive. Potential biological mechanisms underlying these relationships include executive functioning deficits and hyperarousal. Related psychological factors may include thwarted belongingness, perceived burdensomeness, and negative appraisals. Assessing suicide risk in patients with sleep disturbances, and vice versa, is needed. Therapeutic interventions such as cognitive behavior therapy for insomnia and imagery rehearsal treatment, as well as pharmacologic treatments, show promise in treating sleep disorders and suicidal behavior.

Mediation and interaction of problematic internet use in the relationship between sexual minority status and depressive symptoms: Gender-based analysis

BACKGROUND

Previous studies have demonstrated that sexual minorities are at a higher risk of experiencing depressive symptoms. However, few prior investigations have examined the potential mechanisms involved. This study aimed to employ the four-way decomposition approach that integrates the analysis of mediation and interaction to investigate the potential role of problematic internet use between sexual orientation and depressive symptoms.

METHODS

The participants were recruited through a multi-stage, stratified cluster, and random sampling method in China. Students who identified as "gay or lesbian" and "bisexual" were defined as "sexual minorities". The Young's Internet Addiction Test (IAT) was used to evaluate problematic internet use. The Center for Epidemiologic Studies Depression Scale (CESD-20) was used to evaluate depressive symptoms.

RESULTS

A total of 59,859 adolescents were included in this study, with 30,180 (53.25 %) boys and 29,679 (46.75 %) girls. Of these, 7263 (12.13 %) were identified as sexual minorities. Gender differences were observed in the association between sexual orientation, problematic internet use, and depressive symptoms. The mediating effect of problematic internet use was 28.80 % for boys and 36.84 % for girls, respectively. The interaction effect between problematic internet use and sexual minority status on depressive symptoms was 21.19 % and 9.65 % for boys and girls, respectively.

LIMITATIONS

The current study was limited by the cross-sectional design.

CONCLUSION

These findings suggest that prevention and intervention programs aimed at improving mental health outcomes among sexual minority adolescents should prioritize considering the impact of problematic internet use and potential gender differences.

Combination of sugar-sweetened beverage consumption, screen-based sedentary time, and sleep duration and their association with South Korean adolescents' mental health

Introduction

This study examines the combinations of sugar-sweetened beverage (SSB) consumption, screen-based sedentary time, and sleep duration and their association with adolescents' depressive symptoms and suicidal ideation.

Methods

This research followed a crosssectional study design. Secondary data analysis was conducted on the data collected from 21,046 high school students who had participated in the 17th Korea Youth Risk Behavior Web-Based Survey in 2021. A complex sampling analysis, including descriptive and logistic regression analyses, was conducted in SPSS Statistics 26.0.

Results

The combination of low SSB consumption, excessive screen-based sedentary time, and short sleep duration was associated with an increase in depressive symptoms. In addition, a combination of medium/high SSB consumption, appropriate/excessive screen-based sedentary time, and short sleep duration was associated with an increase in depressive symptoms. Finally, the combination of high SSB consumption, excessive screen-based sedentary time, and short sleep duration was associated with an increase in suicidal ideation.

Discussion

The findings demonstrate that healthcare providers should develop and conduct family-and school-based programs to restrict SSB consumption, screen-based sedentary behaviors, and sleep duration to improve adolescents' mental health.

Longitude-based time zone partitions and rates of suicide

BACKGROUND

Increasing evidence suggests that conditions with decreased morning and increased evening light exposure, including shift work, daylight-saving time, and eveningness, are associated with elevated mortality and suicide risk. Given that the alignment between the astronomical, biological, and social time varies across a time zone, with later-shifted daylight exposure in the western partition, we hypothesized that western time zone partitions would have higher suicide rates than eastern partitions.

METHODS

United States (U.S.) county-level suicide and demographic data, from 2010 to 2018, were obtained from a Centers for Disease Control database. Using longitude and latitude, counties were sorted into the western, middle, or eastern partition of their respective time zones, as well as the northern and southern halves of the U.S. Linear regressions were used to estimate the associations between suicide rates and time zone partitions, adjusting for gender, race, ethnicity, age group, and unemployment rates.

RESULTS

Data were available for 2872 counties. Across the U.S., western partitions had statistically significantly higher rates of suicide compared to eastern partitions and averaged up to two additional yearly deaths per 100,000 people (p < .001).

LIMITATIONS

Ecological design and limited adjustment for socioeconomic factors.

CONCLUSIONS

To our knowledge, this is the first study of the relationship between longitude-based time zone partitions and suicide. The results were consistent with the hypothesized elevated suicide rates in the western partitions, and concordant with previous reports on cancer mortality and transportation fatalities. The next step is to retest the hypothesis with individual-level data, accounting for latitude, photoperiodic changes, daylight-saving time, geoclimatic variables, physical and mental health indicators, as well as socioeconomic adversity and protection.

Association between the number of hours of sleep during weekdays and suicidality among Korean adolescents: Mediating role of depressive and anxiety symptoms

BACKGROUND

Adolescent suicide is a serious concern worldwide. Sleep problems are a risk factor for suicide. Therefore, the aim of this study was to evaluate associations between sleep duration and suicidal ideation/suicide attempts and determine the extent to which depressive and anxiety symptoms mediate these associations.

METHODS

Data from 54,948 middle and high school students in South Korea were collected by the stratified cluster method through the Korea Youth Risk Behavior Web-based Survey.

RESULTS

The weighted prevalences of short and long sleep durations were 19.5 % (95 % confidence interval [CI] = 18.9-20.2) and 4.6 % (95 % CI = 4.3-4.8), respectively. Short sleep duration (<5 h/day) increased the odds of suicidal ideation and suicide attempts by 1.43 (95 % CI = 1.29-1.58) and 1.78 (95 % CI = 1.41-2.25), respectively. Long sleep duration (>9 h/day) increased the odds of suicide attempts by 1.5 (95 % CI = 1.02-2.21). Depressive and anxiety symptoms significantly mediated the relationship between sleep duration and suicidal intensity with a satisfactory goodness of fit.

LIMITATIONS

Causal relationships could not be examined due to the cross-sectional study design. Information on other psychopathologies, besides depression and anxiety, was unavailable.

CONCLUSIONS

Short sleep duration was associated with suicidal ideation and suicide attempts among Korean adolescents. Long sleep duration was associated with suicide attempts only. Both depressive and anxiety symptoms mediated the association between sleep duration and suicidal intensity; therefore, both sleep hour restoration and treatment of depressive/anxiety symptoms should be the goals of suicide prevention strategies.

The associations between sleep duration, cognitive function, and depressive symptoms: An analysis of Chinese adolescents from China Family Panel Studies

BACKGROUND

The adverse impact of depressive symptoms on adolescents' physical and psychological health is becoming increasingly prominent. This study aims to examine the association between sleep duration, cognitive function, and depressive symptoms among Chinese adolescents.

METHODS

This study used data on a sample of 3724 adolescents collected from the China Family Panel Studies (CFPS). The multivariate logistic regression was conducted to estimate the association between sleep duration, cognitive function (measured by mathematics and vocabulary), and depressive symptoms among Chinese adolescents; the mediating effects of cognitive function were calculated by mediating model.

RESULTS

The study found that approximately 6.49 % of Chinese adolescents had depressive symptoms, with an average CES-D8 score of 4.27 (SD: 3.11). Adolescents who reported a sleep duration of <6 h/night (OR = 2.34; 95 % CI = 1.30, 4.24) were at a higher risk of depressive symptoms, and the adolescents who had higher mathematics scores (>75 %) were more likely to be at a lower risk of depressive symptoms. Besides, the cognitive function competitively mediated the effect of sleep duration on depressive symptom (indirect effect = 0.043; 95 % CI = 0.023, 0.064).

LIMITATIONS

This is a cross-sectional study; all questions were self-reported; the sleep variable only included the sleep duration.

CONCLUSIONS

Our study highlights that short sleep duration might increase the risk of depressive symptoms, and increasing cognitive function might reduce the occurrence of depressive symptoms in Chinese adolescents. The results displayed that sleep duration had a negatively direct effect on depressive symptoms, but the indirect effects of sleep duration on depressive symptoms via the cognitive function (i.e., mathematics and vocabulary tests) were significantly positive, indicating that the relationship between sleep duration and depressive symptoms was competitively mediated by cognitive function.

Adverse childhood experiences, sexual orientation, and depressive symptoms among Chinese college students: An ecological framework analysis

BACKGROUND

Extensive evidence has demonstrated that adverse childhood experiences (ACEs) predict a high risk of negative health and behavioral outcomes in later life. However, the influence of individuals' psychosocial characteristics and environmental stressors have been mostly omitted in previous research.

OBJECTIVE

This study aimed to examine the prevalence of ACEs among LGB (lesbian, gay, and bisexual) and heterosexual emerging adults, and the associations between different patterns of ACE exposure and depressive symptoms after adjusting for factors at different levels.

PARTICIPANTS AND SETTING

A representative sample of 928 college students in Xiamen city, China was recruited.

METHODS

Latent class analysis was applied to identify the patterns of ACEs. A series of regression analyses were conducted to examine the associations between ACEs and depression and whether ACEs interacted with sexual identity to influence depression, after controlling for individual characteristics, family, school, and society-level factors.

RESULTS

Over 35 % of the participants reported they had experienced at least one type of moderate to extreme childhood maltreatment, and those who identified as LGB reported a higher level of ACE exposure. Higher levels of ACE exposure based on score and clustering approaches were associated with higher risks of depression among Chinese emerging adults. However, the associations between ACEs and depression were not significantly moderated by sexual identity.

CONCLUSIONS

The findings highlighted the importance of early screening for ACEs particularly among sexual minorities and of delivering tailored interventions based on ecological backgrounds. Both the traditional scoring approach and a data-driven approach can be effective in detecting the cumulative effect of ACEs.

Study of suicidal thoughts and intentions with regard to job stress among female medical students living in dormitory with a mental health promotion approach

BACKGROUND

Medical students are exposed to stresses which have irreversible consequences, such as suicidal ideation. The present study aimed to investigate the level of occupational stress in medical students and its relationship with the prevalence of suicidal ideation and attention among them and then provide mental health promotion approaches.

MATERIALS AND METHODS

This cross-sectional descriptive study was performed on 325 undergraduate medical students residing at the dormitory of Shahid Beheshti University of Medical Sciences. The sample size was determined by the census method. Osipow and Suicide Behaviors Questionnaires were used to measure job stress and suicidal ideation, respectively. The condition of entry into the study was living in the dormitory and spent at least one semester. Linear regression and logistic regression were used to examine the relationship between variables.

RESULTS

The mean score of occupational stress among students with a mean age of 21 (±2.18) years was 158.84 (±27.07) and 60% (n = 180) of students had high levels of stress. There was a significant relationship between age and educational level with stress level and suicidal ideation (P < 0.05). They had the highest effect on stress (P = 0.031) and suicidal ideation (P = 0.001), respectively, among students. High level of stress was 11.829 times more likely to have suicidal thoughts than low-stress level (P < 0.001).

CONCLUSIONS

Stress and suicidal ideation are much higher in students of lower semesters and lower ages than students with higher semesters. Students should learn how and with what approach to control and manage exposure to stressors. Measures such as holding stress management training courses as well as managing stressful situations are among the effective measures in improving mental health and reducing stress levels and its effects.

A Comprehensive Review of the Literature on Sleep Difficulties and Suicidality in Youth to Inform an Integrative Developmental Model and Future Directions

Purpose of Review

Suicide is currently the second leading cause of death among youth. Identification of modifiable near-term risk factors can inform suicide prevention strategies. One promising, readily assessed factor is sleep. We critically review the literature on sleep and suicidal thoughts and behaviors among youth.

Recent Findings

Most studies examining the youth sleep-suicidality relationship are from epidemiological samples in which both sleep problems and suicidality were assessed over variable timeframes using limited items from scales not designed to measure these constructs. Nonetheless, these data overwhelmingly support an association between suicidality and a range of sleep difficulties (e.g., insomnia, short/long sleep, weekend oversleep), above and beyond depressive symptoms. Limited studies include clinical samples or prospective designs. We review potential mechanisms and present a developmentally-informed integrative model.

Summary

Literature supports a clear association between sleep difficulties and youth suicidality. Future directions include prospective longitudinal studies and targeted prevention efforts.

Medical and nonmedical use of psychiatric medications among medical students in Riyadh, Saudi Arabia

Introduction:

Psychiatric medication use has increased recently among college students. This includes antidepressants, opioids, stimulants, analgesics, sedatives, and anxiolytics, which could be self-administered without medical supervision.

Objectives:

To determine the prevalence of medical and nonmedical use of psychiatric prescription medications and its correlation with academic performance, demographic data as well as the motives for the nonmedical use.

Methods:

A cross-sectional study aims to assess the psychiatric medication use with or without prescription with the motives behind it, and demographic data of the students at medical colleges in Riyadh, Saudi Arabia.

Results:

A total of 1268 responded to the questionnaire. 251 (20%) of the participants reported using some psychiatric medications in their lifetime, while 191 (15%) participants used some psychiatric medications in the last 12 months. Antidepressants were most used in the surveyed population 144 (57%), followed by opioids/pain relief medications 62 (24%) and anxiolytics 39 (15%). Only 44 surveyed students (3.5%) reported nonmedical use of these psychiatric medications. As for the motives of nonmedical use, the greatest portion reported to use it for “relax or relieve tension” 12 (29%), followed by “relieve pain caused by other health problems” 8 (20%), and “medication to get through the day” 6 (15%).

Conclusion:

Nonmedical use of psychiatric medications among medical students in Riyadh is several times lower than reports by other researchers. Future research should focus on collecting more participants who are using medications without prescription and conduct cross-cultural studies to examine factors contributing to such low rates of illicit psychiatric medication use.

Associations of depressive and anxiety symptoms with non-suicidal self-injury and suicidal attempt among Chinese adolescents: The mediation role of sleep quality

BACKGROUND

Associations of depressive and anxiety symptoms with non-suicidal self-injury (NSSI) and suicide attempt (SA) are not well understood. We aimed to examine these associations among Chinese adolescents, and whether any potential association is mediated through sleep quality.

METHODS

We conducted a cross-sectional study among 1,771 (994 boys [56.1%] and 777 girls [43.9%], mean [SD] age was 12.9 [0.6] years) adolescents who participated in the baseline survey of the Chinese Adolescent Health Growth Cohort (CAHGC) study. Depressive symptoms, anxiety symptoms, NSSI, SA and sleep quality were measured by validated questionnaire. Logistic regression models were employed to estimate the associations of depression and anxiety with NSSI and SA. Mediation analyses were conducted to explore the mediate effect of sleep quality.

RESULTS

The 12-month prevalence of NSSI and SA was 17.1 and 8.3%, respectively. Depressive and anxiety symptoms were significantly associated with NSSI (the adjusted odds ratio [aOR] was 1.89 [95% CI 1.34-2.65] for depressive symptoms and 2.84 [95% CI 2.05-3.94] for anxiety symptoms) and SA (the aOR was 3.20 [95% CI 2.03-5.05] for depressive symptoms and 2.98 [95% CI 1.84-4.84] for anxiety symptoms). No significant gender differences were found in the associations. The mediation proportion of sleep quality on the association of depressive and anxiety symptoms with NSSI, as well as depressive and anxiety symptoms with SA were 21.1, 13.9, 13.6, and 14.7, respectively.

CONCLUSION

Independent associations of depressive and anxiety symptoms with NSSI and SA were observed in Chinese adolescents, and there were no significant gender differences in the associations. Moreover, these associations were partially mediated through sleep quality. Targeted interventions for adolescents' NSSI and SA should focus on those who have depressive and anxiety symptoms, and poor sleep quality.

Prevalence of depression and its associated factors among adolescents in China during the early stage of the COVID-19 outbreak

Background

The outbreak of the 2019 coronavirus disease outbreak (COVID-19) had a detrimental impact on adolescents’ daily life and studying, which could increase the risk of depression. This study examined the prevalence of depressive symptoms (depression hereafter) among Chinese adolescents and its associated factors.

Methods

An online survey was conducted during the COVID-19 outbreak in China. Adolescents aged 11–20 years who currently lived in China were invited to participate in the study. Data were collected with the “SurveyStar” platform using the Snowball Sampling method. Depression was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D).

Results

A total of 9,554 adolescents participated in the study. The prevalence of depression was 36.6% (95% CI [35.6%–37.6%]); the prevalence of mild and moderate-severe depression was 9.2% (95% CI [8.9%–9.5%]) and 27.4% (95% CI [26.9%–27.9%]), respectively. Female gender (OR = 1.235, P < 0.001), senior secondary school grade (OR = 1.513, P < 0.001), sleep duration of <6 h/day (OR = 2.455, P < 0.001), and living in Hubei province (total number of infected cases > 10,000) (OR = 1.245, P = 0.038) were significantly associated with higher risk of depression. Concern about COVID-19 (OR = 0.632, P < 0.001), participating in distance learning (OR = 0.728, P = 0.001), sleep duration of >8 h/day (OR = 0.726, P < 0.001), exercise of >30 min/day, and study duration of ≥4 h/day (OR = 0.835, P < 0.001) were associated with lower risk of depression.

Conclusion

Depression was common among adolescents in China during the COVID-19 outbreak. Considering the negative impact of depression on daily life and health outcomes, timely screening and appropriate interventions are urgently needed for depressed adolescents during the COVID-19 outbreak.

Associations of FKBP5 polymorphisms and methylation and parenting style with depressive symptoms among Chinese adolescents

BACKGROUND

Genetic factors may interplay with environmental stressors to contribute to risks of depressive symptoms. This study aimed to investigate the association of FKBP5 polymorphisms and DNA methylation with depressive symptoms among Chinese adolescents, considering the role of parenting style.

METHODS

This study used a nested case-control study design based on a cohort study, and the case (n = 120) and control groups (n = 118) were matched with age. Depressive symptoms, parenting style, and other demographics were measured. Fourteen potential polymorphisms and one promoter region in the FKBP5 gene were selected for genotyping and methylation analysis.

RESULTS

In the adjusted models, a significant association between FKBP5 rs7757037 and depressive symptoms was found in the codominant model (AG vs. GG; adjusted odds ratio [AOR] = 2.56, 95% CI = 1.13-5.78) and dominant model (AA+AG vs. GG; AOR = 2.38, 95% CI = 1.11-5.120); rs2817032 and rs2817035 polymorphisms were associated with depressive symptoms in the codominant model and dominant model. Significant interactions between rs7757037 and the father's parenting style were found in the codominant model (P = 0.043) and dominant model (P = 0.043), but the gene-environment interactions were not significant after correcting for multiple testing. Moreover, the significant main effects of FKBP5 methylation status on depressive symptoms were not observed, and there was no significant interaction between FKBP5 methylation status and parenting style on depressive symptoms.

CONCLUSIONS

Further studies are required to confirm the effect of FKBP5 polymorphisms and methylation as well as their interactions with parenting styles in larger samples.

Suicidal ideation and suicide attempts: associations with sleep duration, insomnia, and inflammation

BACKGROUND

Sleep disturbance has been consistently identified as an independent contributor to suicide risk. Inflammation has emerged as a potential mechanism linked to both sleep disturbance and suicide risk. This study tested associations between sleep duration, insomnia, and inflammation on suicidal ideation (SI) and history of a suicide attempt (SA).

METHODS

Participants included 2329 adults with current or remitted depression and/or anxiety enrolled in the Netherlands Study of Depression and Anxiety. Sleep duration, insomnia, past week SI, and SA were assessed with self-report measures. Plasma levels of C-reactive protein, interleukin-6, and tumor necrosis factor-α were obtained.

RESULTS

Short sleep duration (⩽6 h) compared to normal sleep duration (7-9 h) was associated with reporting a prior SA, adjusting for covariates [adjusted odds ratio (AOR) 1.68, 95% CI 1.13-2.51]. A higher likelihood of SI during the past week was observed for participants with long sleep duration (⩾10 h) compared to normal sleep duration (AOR 2.22, 95% CI 1.02-4.82), more insomnia symptoms (AOR 1.44, 95% CI 1.14-1.83), and higher IL-6 (AOR 1.31, 95% CI 1.02-1.68). Mediation analyses indicated that the association between long sleep duration and SI was partially explained by IL-6 (AOR 1.02, 95% CI 1.00-1.05).

CONCLUSIONS

These findings from a large sample of adults with depression and/or anxiety provide evidence that both short and long sleep duration, insomnia symptoms, and IL-6 are associated with the indicators of suicide risk. Furthermore, the association between long sleep duration and SI may operate through IL-6.

The Longitudinal Association between Sleep Duration and Suicidal Behavior among Chinese Adolescents: The Role of Nonmedical Use of Prescription Drug

OBJECTIVE/BACKGROUND

Abnormal sleep and nonmedical use of prescription drugs are known to be factors associated with suicidal behavior, but the nature of the association between weekday sleep duration and suicidal behavior has not been elucidated. Nonmedical use of prescription drugs may play a mediator role in the association mentioned above.

PARTICIPANTS

There were a total of 3,273 high school students interviewed at baseline with a response rate of 96.8% and followed up at one year (retention rate, 96.1%). The mean (SD) age of the students was 13.7 (1.0) years.

METHODS

Data were drawn from the longitudinal data of the School-based Chinese Adolescents Health Survey. A total of 12 high schools were selected in Guangzhou. Suicidal behavior, weekday sleep duration, and nonmedical use of prescription drugs were measured.

RESULTS

Sleeping < 7 hours/day at time 0 was positively associated with suicidal ideation (Adjusted odds ratio [AOR] = 1.51, 95% CI = 1.21-1.89) and suicide attempts (AOR = 2.35, 95% CI = 1.02-5.38) at time 1. The mediation analyses showed that baseline opioids misuse or sedatives misuse partially mediated the associations of baseline short weekday sleep duration with suicidal ideation and suicide attempts at one-year follow-up.

CONCLUSIONS

Baseline short weekday sleep duration was positively associated with subsequent suicidal ideation and suicide attempts, and nonmedical use of opioids or sedatives partially mediated the associations mentioned above. Suicidal behavior can be prevented, short weekday sleep duration and nonmedical use of prescription drugs may be risk factors for suicidal behavior, and the respective roles of these factors are needed to be better understood.

Association between snoring and depressive symptoms in adolescents

While previous studies have suggested that snoring may be associated with depressive symptoms and suicidality in adults and preschool children, there have been no investigations in non-clinical adolescent populations. This study aimed to demonstrate the association between snoring and depressive symptoms/suicidality in adolescents. This survey study recruited 8530 students (grades 7-11) and examined depressive symptoms, suicidality, snoring frequency, daytime sleepiness, sleep duration, and presence of insomnia by questionnaires. Correlation analyses, multiple linear regression analyses and mediation analyses were performed to determine the association between snoring frequency and depressive symptoms/suicidality. The study population included 8080 students (16.73 ± 1.09 years old). Snoring frequency was positively correlated with depressive symptoms and suicidality. Snoring frequency was associated with depressive symptoms and suicidality when adjusted for age and sex, and the association remained significant after additionally adjusting for sleep duration, insomnia, and daytime sleepiness. When depressive symptoms were included as a predictor of suicidality, snoring frequency showed no significant predictive value. Mediation analysis confirmed that depressive symptoms mediate the association between snoring frequency and suicidality. Our findings suggest that self-reported complaints of snoring are associated with increased depressive symptoms and suicidality in adolescents independently of sleep duration, insomnia, and daytime sleepiness, and the connection between snoring and suicidality is mediated by depressive symptoms. These data underscore the importance of identifying snorers among adolescents and screening for depression and suicidal ideation in this population.

Prevalence, risk factors and clinical correlates of suicidal ideation in adolescent patients with depression in a large sample of Chinese

BACKGROUND

Suicidal ideation (SI) has a high risk in adolescents and is now a significant concern due to its problematic outcome. However, few systemic studies of suicidal ideation have been conducted in adolescent patients. Therefore, the current study was aimed to assess the prevalence and its clinical correlate of suicidal ideation among adolescent patients with depression.

METHODS

A total of 1635 adolescent patients (748 males/ 887 females) with depression were recruited in this study. The clinical and demographic data were collected by a self-administered questionnaire. Suicidal ideation was assessed by interview. Children's Depression Inventory (CDI) was used to evaluate depressive symptoms, Adolescent Self-Rating Life Events Check List (ASLEC) was used to assess the stressful life events.

RESULTS

The study showed that the prevalence of suicidal ideation in adolescent depression patients was 38.2% (625/1635). Compared to the non-SI patients, SI patients had greater scores on CDI and ASLEC, had inadequate sleeping time, and were more likely to be females. Further logistic regression analysis indicated that suicidal ideation in adolescent patients with depression was significantly associated with females, inadequate sleeping time, the severity of depression, and higher learning pressure.

LIMITATIONS

No causal relationship could be drawn due to the cross-sectional design.

CONCLUSIONS

Our results suggest a high prevalence of suicidal ideation in adolescents with depression. Moreover, the severity of depression, sex, sleep time, and learning pressure are all related to suicidal ideation. Early recognition and treatment of suicidal ideation can effectively prevent the occurrence of suicide among adolescent patients.

The Associations between Sleep Duration, Academic Pressure, and Depressive Symptoms among Chinese Adolescents: Results from China Family Panel Studies

Depressive symptoms are a common mental health problem among adolescents, which may affect their physical and mental health development and impose heavy burdens on individual families and society. This study aimed to examine the associations between sleep duration, academic pressure, and depressive symptoms among Chinese adolescents and to construct the mediation model to explore the mediating effect of sleep duration. The data are from the China Family Panel Studies (CFPS). Methodologically, the aforementioned associations were explored by constructing a structural equation model and applying multivariate multilevel logistic regression. In this study, we found that approximately 6.49% of the 3724 Chinese adolescents had depressive symptoms. Sleep duration of <6 h/night (OR = 2.39, 95%CI = 1.33-4.32) and high/maximum academic pressure (high: OR = 1.43, 95%CI = 1.02-1.99; maximum: OR = 2.43, 95%CI = 1.58-3.73) were both associated with an increased risk of depressive symptoms in adolescents. Meanwhile, the multiplicative interaction between sleep duration and academic pressure was significantly associated with depressive symptoms in adolescents (p < 0.001). The sleep duration played a partial mediating role in the relationship between academic pressure and depressive symptoms (a*b = 0.006, 95%BootCI = 0.001-0.012). Our study highlights that it is essential to mitigate the academic pressure of adolescents to increase their sleep duration and further reduce the occurrence of depressive symptoms by adopting corresponding preventive measures.

Sleep Duration Is Closely Associated with Suicidal Ideation and Suicide Attempt in Korean Adults: A Nationwide Cross-Sectional Study

Introduction: Suicidal ideation and suicide attempts are major risk factors for suicidal death, and sleep problems are associated with an increased risk for mental disorders. We investigated the relationship between sleep duration and suicidal ideation and suicide attempts in a representative sample of the Korean general population from a nationwide survey. Methods: We analyzed data collected from the Korea National Health and Nutrition Examination Survey VI and VII (2013–2018). Suicidal ideation was identified via self-report, and we accessed suicide attempt history. Sleep duration was divided into three categories: short sleep duration (SSD) (≤5 h), normal sleep duration (NSD) (>5 and <9 h), and long sleep duration (LSD) (≥9 h). Sampling weights were applied to obtain estimates for the general Korean population. Results: Overall, 4015 (12.0%), 25,609 (76.5%), and 3857 (11.5%) participants were in the SSD, NSD, and LSD groups, respectively. Among these groups, 7.2%, 2.8%, and 3.3% reported suicidal ideation; while 1.2%, 0.4%, and 0.7% reported a history of suicide attempts. Multiple regression analyses revealed that SSD was significantly more strongly associated with suicidal ideation (adjusted odds ratio (AOR) 1.46, p < 0.001) and attempts (AOR 2.05, p = 0.003) than NSD. No association was found between LSD and suicidal ideation/attempts. Conclusion: Sleep duration is significantly associated with suicidal behavior, and SSD was particularly closely related with an increased risk for suicidal ideation and suicide attempt. Clinicians should carefully consider sleep duration in suicidal patients.

Insomnia in the context of short sleep increases suicide risk

Study Objectives

The relationship between insomnia and suicide risk is not completely understood. We aimed to investigate the influence of insomnia on suicide risk, taking both sleep duration and depression into consideration.

Methods

The present study is based on a Swedish prospective cohort study of 38,786 participants with a mean follow-up time of 19.2 years. Cox proportional hazards models with attained age as time-scale were used to estimate hazard ratios (HRs) of death by suicide with 95% confidence intervals (CI) for participants categorized by frequency of insomnia symptoms. Causal mediation analysis was performed to assess to what extent the relationship between insomnia and suicide risk is mediated by depression.

Results

Insomnia was only associated with suicide risk among short sleepers, whereas no significant association was observed among those who slept 7 h/night or more. The total effect of insomnia in the context of short sleep on suicide risk, expressed on the HR scale, was 2.85 (95% CI 1.42–5.74). The direct effect was 2.25 (95% CI 1.12–4.54) and the indirect effect, mediated by depression, was 1.27 (95% CI 1.05–1.53). Of the total effect, 32% was mediated by depression. The association between insomnia and suicide risk became more pronounced with decreasing depressive symptoms (p value for trend <0.05).

Conclusions

Insomnia in the context of short sleep increases suicide risk, both directly and indirectly by affecting the risk of depression. Abnormalities of sleep duration and insomnia symptoms should be evaluated when assessing suicide risk.

Clinical features of the patients with major depressive disorder co-occurring insomnia and hypersomnia symptoms: a report of NSSD study

BACKGROUND

The co-occurrence of insomnia and hypersomnia symptoms in patients with major depressive disorder (MDD) is associated with suicidal ideation and functional impairment. The relationship between sleep disturbances and clinical features and outcomes may not be adequately studied. In this study, we measured the functional impairments and clinical features of co-occurring insomnia and hypersomnia symptoms in Chinese patients with MDD.

METHODS

A post-hoc analysis was performed on data from the National Survey on Symptomatology of Depression (NSSD), which assessed the MDD patients in 32 hospitals by a clinician-rating questionnaire. The clinical features and outcomes were compared among the following four groups: insomnia symptom only, hypersomnia symptom only, both insomnia and hypersomnia symptoms, no sleep disturbance, respectively.

RESULTS

Totally, 234 (7.15%) of 3275 participants with MDD co-occurred insomnia and hypersomnia symptoms. They had more depressive symptoms (27.41 ± 9.123), higher rate of suicide ideation (39.7%), more severe impairment in physical (58.1%), economic (32.9%), work (55.1%), and relationship with families (29.5%). Patients with both sleep disturbances were more likely to excessive worry about sleep, have suicidal ideation, the distress of social disharmony, more somatic symptoms, lack of energy, hyperphagia, loss of mood reactivity, and diurnal change, whereas less likely to have anxious mood.

LIMITATIONS

Sleep disorders were not diagnosed by current standard diagnostic criteria.

CONCLUSIONS

Patients co-occurring with both sleep disturbances are associated with a higher rate of suicide risk and poorer social function. Our study could provide implications for suicidal risk evaluation and the development of therapeutic strategies for depression.

The prospective associations between different types of sleep disturbance and suicidal behavior in a large sample of chinese college students

BACKGROUND

Sleep disturbance can be an important predictor associated with suicide behaviors. However, to date, few studies have examined the prospective relationships between different types of sleep disturbance and suicidal behaviors. The current study examined which sleep disturbance types were independent risk factors for subsequent suicidal behaviors in a large sample of Chinese college students.

METHODS

Data came from a large-scale health-related cohort study in Guangdong, China. Participants were 11,740 college students initially assessed in March and April in 2019 and reassessed six month later. Self-administered structured questionnaires were used to assess suicidal behaviors, insomnia, nightmares, sleep disordered breathing (SDB) symptoms, restless legs syndrome (RLS) symptoms, depression, substance abuse and demographic characteristics. A series of logistic regression analyses were conducted to examine the associations between different types of sleep disturbance and suicidal behaviors.

RESULTS

Overall, 12.2% and 1.2% of college students reported suicidal ideation and attempts at baseline, and 8.6% and 2.4% reported similar behavior at follow-up. After adjustment for key covariates and prior suicidal behaviors, frequent nightmares (AORs = 1.35-1.69) and RLS symptoms (AOR = 1.37) at baseline predicted subsequent suicidal ideation, and only frequent nightmares (AOR = 2.40) at baseline predicted subsequent suicidal attempts.

LIMITATIONS

All measures were based on self-report instead of objective assessments or clinical diagnostic evaluations.

CONCLUSIONS

Frequent nightmares and RLS symptoms were independently associated subsequent suicidal ideation or attempts. Screening and managing sleep disturbance may be helpful for reducing the risk of suicidal behaviors among college students.

Association of sexual minority status, gender nonconformity with childhood victimization and adulthood depressive symptoms: A path analysis

BACKGROUND

Sexual minority status and childhood gender nonconformity have been associated with elevated risks of childhood adversities and poorer mental health.

OBJECTIVE

To explore how abuse and bullying explain the disparities in the associations of sexual minority status and childhood gender nonconformity with adulthood depressive symptoms in men.

PARTICIPANTS AND SETTING

We conducted a cross-sectional study using a self-report questionnaire among Chinese adult men (18-35 years) who were identified as heterosexual (n = 873) and sexual minority (n = 858) in Guangzhou from 2017 to 2019.

METHODS

Structural equation modeling (SEM) were conducted for path analysis.

RESULTS

The levels of exposure to childhood maltreatment were higher in sexual minorities than in straight men, and sexual minority status predicted an increased risk of depressive symptoms via childhood maltreatment (indirect effect: β = 0.026, p = 0.004). Meanwhile, childhood gender nonconformity predicted higher depressive symptoms via both family (indirect effect: β = 0.042, p < 0.001) and school (indirect effect: β = 0.028, p < 0.001) victimization, and there was a direct effect (β = 0.154, p < 0.001) of gender nonconformity on depressive symptoms.

CONCLUSION

Sexual minority status and gender nonconformity are indicators of men's increased risk of childhood victimization and adulthood depressive symptoms. As a result, intervention based on both family and school dimensions needs to be developed.

When Night Falls Fast: Sleep and Suicidal Behavior Among Adolescents and Young Adults

Sleep disturbances have been linked to suicidal ideation and behaviors in adolescents. Specifically, insomnia and nightmares are associated with current suicide risk and predict future ideation. Associations between hypersomnia, sleep apnea, and suicide remain inconclusive. Potential biological mechanisms underlying these relationships include executive functioning deficits and hyperarousal. Related psychological factors may include thwarted belongingness, perceived burdensomeness, and negative appraisals. Assessing suicide risk in patients with sleep disturbances, and vice versa, is needed. Therapeutic interventions such as cognitive behavior therapy for insomnia and imagery rehearsal treatment, as well as pharmacologic treatments, show promise in treating sleep disorders and suicidal behavior.

Suicidal ideation among nurses: Unique and cumulative effects of different subtypes of sleep problems

BACKGROUND

Nurses have high rates of sleep problems, and higher risk of suicide than the general population. However, there is no empirical evidence showing the extent to which sleep problems among nurses are related to suicidal ideation.

METHODS

Multistage stratified cluster sampling was performed to recruit nurses from tertiary hospitals in Shandong, China. Item 9 of the Patient Health Questionnaire-9 was used to assess suicidal ideation. The Pittsburgh Sleep Quality Index was used to assess different subtypes of sleep problems.

RESULTS

Overall prevalence of suicidal ideation among the sample was 10.8%. Nurses with sleep problems were at high risk for suicidal ideation (^bOR = 1.79, 95% CI = 1.20-2.65). Among different sleep problem subtypes, only "cannot breathe comfortably" was independently related to suicidal ideation. Different subtypes of sleep problems had cumulative effects on suicidal ideation: the more subtypes of sleep problems nurses experienced, the higher the likelihood of suicidal ideation.

LIMITATIONS

The cross-sectional study design prevents inferring causation, and the use of self-report measures may lead to recall bias. Other physical/mental conditions, besides depression, were not assessed. Statistical power may have been insufficient due to the small sub-sample who reported suicidal ideation. Also, the generalizability of the results is limited, as the sample only comprised nurses in tertiary hospitals.

CONCLUSIONS

Nurses experiencing sleep problems were associated with increased likelihood of suicidal ideation. It may be beneficial to incorporate sleep problems into routine screening and intervention for suicide prevention in clinical practice.

Association between Childhood Maltreatment and Suicidal Ideation and Suicide Attempts among Chinese Adolescents: The Moderating Role of Depressive Symptoms

Suicidal behavior is a major public health concern worldwide and has become the second-leading cause of death among adolescents. The purposes of this study were to investigate the associations between childhood maltreatment and suicidal behavior and to test whether depressive symptoms have moderating effects on these associations. A multistage stratified cluster randomized sampling method was adopted to collect data from 21,019 high school students in Guangdong Province, China. The prevalence of suicidal ideation and suicide attempts among Chinese adolescents were 18.2% and 3.6%, respectively. Physical abuse (adjusted odds ratios (AOR) = 1.35, 95% confidence intervals (CI) = 1.32–1.38), emotional abuse (AOR = 1.26, 95% CI = 1.25–1.28), sexual abuse (AOR = 1.25, 95% CI = 1.21–1.30), physical neglect (AOR = 1.09, 95% CI = 1.08–1.11), and emotional neglect (AOR = 1.08, 95% CI = 1.08–1.09) were all associated with an increased risk of suicidal ideation, and these associations were also found for suicide attempts. According to stratification analyses, physical abuse/emotional abuse/sexual abuse had a stronger effect on suicidal ideation and suicide attempts among students without depressive symptoms than among students with depressive symptoms. Childhood maltreatment was associated with an increased risk of suicidal ideation and suicide attempts in Chinese adolescents. Depressive symptoms play a moderating role in the association between childhood maltreatment and suicidal behaviors.

Association between habitual weekday sleep duration and depressive symptoms among Chinese adolescents:The role of mode of birth delivery

BACKGROUND

Depressive symptoms among adolescents are common. This study aimed to assess, among Chinese adolescents, the associations of habitual weekday sleep duration with depressive symptoms and whether these associations varied with the mode of birth delivery.

METHODS

Data were from the 2015 School-based Chinese Adolescents Health Survey, and 150,053 students' questionnaires were qualified for analysis. Multi-level logistic regression models were performed.

RESULTS

A weekday sleep duration of ≤5 h/night was associated with depressive symptoms (adjusted odds ratio [aOR]=2.98, 95% CI=2.75-3.24), and adolescents who reported a weekday sleep duration of 5-7 h/night (aOR=1.69, 95% CI=1.60-1.79) and >9 h/night (aOR=1.28, 95% CI=1.11-1.45) were also at a higher risk of depressive symptoms. Stratification analyses showed that in both adolescents delivered by vaginal birth and cesarean section (CS), a weekday sleep duration of ≤5 h/night, 5-7 h/night, and >9 h/night were associated with the increased risk of depressive symptoms in the adjusted models, and the magnitudes of the aORs in adolescents delivered by CS were slightly higher than those in adolescents delivered by vaginal birth.

LIMITATIONS

The cross-sectional study design and self-reported sleep duration and depressive symptoms.

CONCLUSION

This study demonstrates a significant U-shaped association between weekday sleep duration and depressive symptoms among Chinese adolescents. In both adolescents delivered by vaginal birth and CS, those who reported having abnormal sleep duration were at a high risk of depressive symptoms. Based on the findings of this study, we suggest sleep duration and mode of delivery should be a matter of concern for public health authorities.

Sleep problems and suicide risk in youth: A systematic review, developmental framework, and implications for hospital treatment

OBJECTIVE

Sleep problems are transdiagnostic symptoms that confer significant risk for suicidal thoughts and behaviors (STBs) in adults. However, less is known about the sleep-STB association in adolescence-a developmental period when rates of STBs increase drastically, and sleep problems may be particularly pernicious. This article provides a systematic review of research on the sleep-STB association in youth, an overview of changes in sleep regulation during adolescence that may make sleep problems particularly detrimental for youth, and a discussion of the clinical implications of the sleep-STB association for hospitalized youth.

METHOD

The systematic review included all longitudinal studies in which sleep problems were examined as prospective predictors of STBs in adolescents (aged 10-24 years). The search was conducted on December 1, 2017 using PsychINFO, PubMed, and Web of Science databases.

RESULTS

Ten studies qualified for inclusion in this review. Of these, seven studies found at least one type of sleep problem significantly predicted a STB outcome.

CONCLUSIONS

Although findings are mixed, growing research suggests that sleep problems may be a unique risk factor for STBs in youth. Sleep problems may be particularly important intervention target because they are easily assessed across healthcare settings and are amenable to treatment.

Association Between Bullying and Suicidal Behavior Among Chinese Adolescents: An Analysis of Gender Differences

Background

Suicide has become the leading cause of death among 15-34 years old in China, and more attention should be paid to risk factors and prevention of suicidal ideation and suicide attempts. The school-based survey was conducted to test the associations of bullying behavior with suicidal ideation and suicide attempts, and to assess whether the biological gender can moderate these associations.

Methods

A multistage stratified cluster sampling method was used to recruit participants from high schools in Guizhou, China, and univariate and multivariate logistic regression models were fitted.

Results

A total of 23,392 students were included in the analysis, and 45.4% were boys. The mean age of the students was 15.2 (SD: 1.9) years. Overall, 3.8% (882) of the students were victims, 4.9% (1144) were bullies, and 3.2% (736) were bully-victims. A total of 18.9% of students reported having suicidal ideation, and 3.9% reported having suicide attempts. Victims (adjusted odds ratio [AOR]=2.15, 95% CI=1.84-2.51), bullies (AOR=3.17, 95% CI=2.78-3.62), and bully-victims (AOR=3.18, 95% CI=2.71-3.73) were at an elevated risk of suicidal ideation than neutrals; similar associations can be found in the associations between bullying behavior and suicide attempts. Further stratification analyses showed that the associations of being bullied or bullying others with suicidal ideation and suicide attempts were slightly stronger in girls than in boys.

Conclusion

Prevention or intervention programs are recommended to take the biological gender into consideration, and future studies are also warranted to investigate the reasons of differences by gender in the association of bullying and suicidal behavior.

Associations of Substance Use Behaviors With Suicidal Ideation and Suicide Attempts Among US and Chinese Adolescents

Background: Adolescence has been described as a period of increased health risk-taking behaviors. Given the variety of cultural contexts, healthcare systems, and public health policies in different regions, the present study aimed to determine whether there are similar or different associations of substance use behaviors with suicidal ideation and suicide attempts among US and Chinese adolescents. Methods: This study included a total of 14,765 US adolescents from the 2017 National Youth Risk Behavior Surveillance System (YRBSS) and 24,345 Chinese adolescents from the 2017 School-based Chinese Adolescents Health Survey (SCAHS). Results: The proportions of suicidal ideation and suicide attempts were 17.4 and 5.7% among US adolescents, which were higher than those among Chinese adolescents (suicidal ideation: 13.7% and suicide attempts: 2.7%). Among Chinese adolescents, the most common substance use behavior was "alcohol use (55.4%)," followed by "cigarette use (11.6%)." Among US adolescents, the most popular substance was alcohol (ever used: 55.9%), followed by marijuana (ever used: 34.6%). Moreover, alcohol use was significantly related to suicidal ideation/suicide attempts only in Chinese adolescents [suicidal ideation: Adjusted odds ratio (AOR) = 1.88, 95% CI = 1.71~2.06; suicide attempts: AOR = 2.12, 95% CI = 1.71~2.63], and marijuana use was associated with suicidal ideation and suicide attempts only in the US adolescent group (suicidal ideation: AOR = 1.23, 95% CI = 1.06~1.44; suicide attempts: AOR = 1.51, 95% CI = 1.21~1.87). Moreover, although the associations of prescription pain medication use with suicide attempts were significant in both Chinese and US adolescent groups, the adjusted associations were stronger in Chinese adolescents than in US adolescents (Chinese adolescents: AOR = 3.97, 95% CI = 2.76~5.72; US adolescents: AOR = 1.76, 95% CI = 1.43~2.16; P < 0.05). Conclusions: The associations of alcohol use with suicidal ideation and suicide attempts were only significant in Chinese adolescents. Marijuana use was associated with suicidal ideation and suicide attempts only in the US adolescent group. Although the associations of prescription pain medication use with suicide attempts were significant in both Chinese and US adolescent groups, the adjusted associations were significantly stronger for Chinese adolescents. These findings might be related to the differences in cultural contexts, healthcare systems, and public health policies in the two different countries.

Gender Differences in the Relationship Between Sleep Problems and Suicide Attempt in Adolescents

There are few studies examining which types of sleep problems are independently associated with suicide attempt (SA) and gender difference in adolescents. The aim of the present study was to examine whether specific sleep problems were uniquely associated with suicide attempt in adolescents and explore gender differences in the association. A school-based health survey was conducted in four provinces within China from November 2014 to January 2015. A total of 15,132 students aged 10-21 years completed standard questionnaires assessing past 12 month suicide attempt in addition to measures of sleep quality, quantity and sleep beliefs. 5.4% of participants reported a suicide attempt within the last 12 months. After adjustment for sociodemographic variables and psychological symptoms, almost all sleep problems remained significantly associated with a greater endorsement of suicide attempt. Further adjustment for co-occurring sleep problems revealed that weekday sleep duration (<6, 8-10, and ≥10 h), insomnia (often), and nightmares (sometimes and often) remained independently associated with suicide attempt in boys (p < 0.05). However in girls, weekday sleep duration (<6 and ≥10 h), weekend sleep duration (<6 h), midday nap (0 or 1-2 d/week), insomnia (sometimes and often), nightmare (often) and sleep beliefs (high) were independently associated with suicide attempt (p < 0.05). Multiple sleep problems are associated with suicide attempt in adolescents, however the relationship varies by gender.

Association of emotional and behavioral problems with single and multiple suicide attempts among Chinese adolescents: Modulated by academic performance

BACKGROUND

There were differences in the characteristics and prevalence rates between individuals with a history of one suicide attempt and those with multiple suicide attempts. This large-scale study was conducted to test, among Chinese adolescents, the associations of emotional and behavioral problems with single and multiple suicide attempts and whether these associations vary with adolescents' academic performance.

METHODS

Data were drawn from the 2019 School-based Chinese Adolescents Health Survey (n = 20,702). Information about emotional and behavioral problems, suicide attempts, suicidal ideation, academic performance, and sleep duration was gathered. Multinomial logistic regression models using Firth penalized likelihood approach and appropriate sampling weights were performed.

RESULTS

Compared with no suicide attempt, peer problems, emotional problems, conduct problems, and hyperactivity were associated with an elevated risk of both a single suicide attempt and multiple suicide attempts, respectively (P < 0.05); the magnitudes of these associations in multiple suicide attempters were higher than those in single suicide attempters. Further stratification analyses by academic performance showed a greater association of the four difficulties with multiple suicide attempts in adolescents reporting poor academic performance than in those with good or average academic performance.

LIMITATIONS

The school-based study sample only included students, and causal inference could not be delineated due to the cross-sectional design.

CONCLUSIONS

Emotional and behavioral problems are associated with an elevated risk of single and multiple suicide attempts with differences between multiple suicide attempters and single suicide attempters. Adolescent academic performance plays a modulating role in these associations for multiple suicide attempts.

Long-term exposure to ambient fine particulate pollution, sleep disturbance and their interaction effects on suicide attempts among Chinese adolescents

BACKGROUND

There is a lack of literature about the joint effects of PM_2.5 exposure and sleep disturbance on suicide attempts. This study aimed to estimate the association of PM_2.5 exposure or sleep disturbance with suicide attempts among Chinese adolescents and to test their interaction effects on both additive and multiplicative scales.

METHODS

Data was drawn from a subsample of the School-based Chinese Adolescents Health Survey (SCAHS) during 2014-2015 in Guangdong province, including 21,780 eligible participants. The 3-year (2011-2013) annual average concentration of PM_2.5 was estimated using satellite data. Multi-level logistic regression models with weights were fitted, and both multiplicative and additive interactions for PM_2.5 and sleep disturbance were tested.

RESULTS

A total of 608 students (2.8%) reported having suicide attempts. After adjusting for significant demographics and depressive symptoms, PM_2.5 exposure (Adjusted odds ratio [AOR] = 1.25, 95% CI = 1.03-1.56) and sleep disturbance (AOR = 1.69, 95% CI = 1.41-2.02) were positively associated with suicide attempts, respectively. The adjusted additive interaction effect of PM_2.5 and sleep disturbance was 2.42 (95% CI = 1.80-3.26) with a synergistic index of 1.31. The multivariable multi-level logistic regression models did not find any significant multiplicative interaction item (P > 0.05).

LIMITATION

The school-based cross-sectional study design CONCLUSION: Long-term exposure to PM_2.5 may elevate the risks of suicide attempts among Chinese adolescents. Moreover, the significant interaction effects of PM_2.5 exposure and sleep disturbance on suicide attempts were found in the additive model, suggesting decreasing long-term exposure to a higher level of PM_2.5 may be helpful to reduce the risk of suicide attempts among adolescents with sleep disturbance.

Systematic review and meta-analysis of the relationship between sleep disorders and suicidal behaviour in patients with depression

BACKGROUND

The potential link between sleep disorders and suicidal behaviour has been the subject of several reviews. We performed this meta-analysis to estimate the overall association between sleep disorders and suicidal behaviour and to identify a more specific relationship in patients with depression.

METHODS

A systematic search strategy was developed across the electronic databases PubMed, EMBASE and the Cochrane Library from inception to January 1, 2019 for studies that reported a relationship between sleep disorders and suicidal behaviour in depressed patients. The odds ratio (OR) and corresponding 95% confidence interval (CI) were used to measure the outcomes. Heterogeneity was evaluated by Cochran's Q test and the I² statistic. The Newcastle-Ottawa Scale (NOS) was adopted to evaluate the methodological quality of each of the included studies, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the evidence. We calculated the overall association between sleep disorders and suicidal behaviour and estimated more specific categories, including insomnia, nightmares, hypersomnia, suicidal ideation, suicide attempt, and completed suicide.

RESULTS

A total of 18 studies were included in this study. Overall, sleep disorders were closely related to suicidal behaviour in patients with depression (OR = 2.45 95% CI: 1.33 4.52). The relatively increased risks of sleep disorders with suicidal ideation, suicide attempt and completed suicide ranged from 1.24 (95% CI: 1.00 1.53) to 2.41 (95% CI: 1.45 4.02). Nightmares were found to be highly correlated with the risk of suicidal behaviour (OR = 4.47 95% CI: 2.00 9.97), followed by insomnia (OR = 2.29 95% CI: 1.69 3.10). The certainty of the evidence was rated as very low for the overall outcome and the major depression subgroup and was rated as low for the depression subgroup.

CONCLUSIONS

This meta-analysis supports the finding that sleep disorders, particularly nightmares and insomnia, increase the risk of suicidal behaviour in depressed patients. Considering that all included studies were observational, the quality of the evidence is rated as very low. More well-designed studies are needed to confirm our findings and to better explain the mechanisms by which sleep disorders aggravate suicidal behaviour in depressed patients.

Association between weekday sleep duration and nonmedical use of prescription drug among adolescents: the role of academic performance

Nonmedical use of prescription drug (NMUPD) among adolescents has increased substantially over the last 2 decades, and evidence suggests that sleep duration may impact upon drug use and academic performance. This study aimed to estimate the prevalence of sleep duration, NMUPD, and academic performance among Chinese adolescents, to test the independent associations of sleep duration with NMUPD, and to investigate whether these associations vary by academic performance. Data were from the 2015 School-based Chinese Adolescents Health Survey using a multi-stage, stratified-cluster, random-sampling method to collect information from 162,601 high school students [mean age (SD) =15.2 (1.9) years; 47.4% were male] from 42 cities in China. The weighted prevalence of sleeping ≤ 5 h/weekday was 1.1% (95% CI, 1.0-1.1%), and the weighted prevalence of sleeping > 9 h/weekday was 7.6% (95% CI 7.4-7.7%). After adjusting for significant covariates and academic performance, the results showed that compared with those with 7-9 h/weekday sleep duration, students reporting ≤5 h/weekday were more likely to misuse opioids (AOR = 2.12, 95% CI 1.73-2.59), sedatives (AOR = 2.00, 95% CI 1.65-2.42), and any prescription drug use (AOR = 1.89, 95% CI 1.60-2.23); students with>9 h/weekday sleep duration were also at a higher risk of opioids use, sedative use, and any prescription drug misuse; the U-shaped association of sleep duration with NMUPD was found. Moreover, there exist significant associations between weekday sleep duration and NMUPD among Chinese adolescents, and academic performance plays a moderating role in the aforementioned associations. The efforts to prevent NMUPD should be focused on adolescents who report abnormal sleep duration or poor academic performance.

Sleep difficulties and suicidality in youth: current research and future directions

Studies have established a clear relationship between subjective sleep problems and the continuum of suicidality in adolescents. These studies are primarily cross-sectional in nature and conducted with epidemiological and depressed clinical samples. More recent studies focus on prospective data. Herein, we provide an update on current studies on the sleep-suicide association among youth. To further the critical mission of youth suicide prevention, future directions include more nuanced study of sleep employing a sleep health framework, longitudinal studies employing both objective and subjective sleep measures, fine-grained temporal associations between these constructs and their fluctuations over time, as well as enhanced understanding of the mechanisms underlying these associations.

A latent class analysis of health lifestyles and suicidal behaviors among US adolescents

BACKGROUND

Previous studies have documented the link between individual health behaviors and suicide, but little is known about the influence of health lifestyles on suicide among adolescents. This study aims to identify the unobserved patterns of health behaviors and to examine their associations with adolescent suicidal behaviors to inform screening of suicidality.

METHODS

Data were derived from a nationally representative sample of adolescents (n = 14,506, ages 12-18, 50.9% female) in the national school-based 2017 Youth Risk Behavior Survey. Latent class analysis was performed based on 13 health behaviors related to diet (e.g., frequency of consuming breakfast, fruits/vegetables, soda), physical activity (frequencies of physical activity, sports team participation), sleep, and media use (TV/computers). Suicidal behaviors were measured by three dichotomized variables, including suicidal ideation, plan, and attempts. Multivariate logistic regressions were used to examine associations between identified classes and suicidal behaviors.

RESULTS

Four classes of health lifestyles were identified. Class 1 (23.6%) consistently engaged in health-promoting behaviors, including eating breakfast daily, high intake of fruits/vegetables, physically active, and infrequent use of TV/computers. Class 2 (37.7%) had an irregular diet, moderate exercise, and high computer use. Class 3 (31.8%) had moderate diet, frequent exercise, and moderate sleep. Class 4 (6.9%) had the lowest engagement in health-promoting behaviors. Class 4 had higher odds of suicide plan than Class 1 (OR = 1.50, 95% CI = 1.10-2.05). Notably, Class 2 and 3 were less likely to attempt suicide than Class 1 (OR = 0.74, 95% CI = 0.57-0.95 for Class 2; OR = 0.65, 95% CI = 0.48-0.89 for Class 3).

LIMITATIONS

Due to the cross-sectional design, no causal inference can be drawn.

CONCLUSIONS

Both Class 1 (consistent) and Class 4 (lowest) engagement in health-promoting behaviors were associated with increased suicidal behaviors. Suicide prevention efforts that examine both lifestyles are keys to early detection of suicidal ideation and plans, and prevention of suicide attempts.

Association between body weight status and suicidal ideation among Chinese adolescents: the moderating role of the child's sex

PURPOSE

Suicidality (ranging from suicidal ideation to suicidal attempts and completed suicide) is a major and preventable public health concern, and body weight is considered a modifiable factor which might be helpful to the early risk assessment of suicidal ideation. This study aimed to comprehensively evaluate the association of body weight status with suicidal ideation across sex among Chinese adolescents.

METHODS

Data were drawn from the 2015 National School-based Chinese Adolescents Health Survey, and 54,640 students' questionnaires were completed and qualified for the survey. Body mass index z scores were calculated and categorized into four levels: underweight (less than the 5th percentile for sex and age), normal weight (between the 5th and 85th percentile), overweight (between the 85th and 95th percentile), and obese (above the 95th percentile).

RESULTS

Of the total sample, 47.3% (25,852) were boys. The weighted prevalence of suicidal ideation among Chinese adolescents is 15.7% (14.6% in boys and 17.3% in girls). After adjusting for demographics, smoking, drinking, and depressive symptoms, our final multivariate logistic regression models demonstrated that only boys identified as underweight (Adjusted odds ratio [AOR] = 1.23, 95% CI = 1.06-1.44) or obese (AOR = 1.19, 95% CI = 1.02-1.38) were at a higher risk of suicidal ideation. Additionally, the association between weight status and suicidal ideation among boys might be moderated by academic pressure, smoking, and depressive symptoms.

CONCLUSIONS

There was a significant J-shaped association between relative body weight and suicidal ideation in boys. The child's sex should be taken into consideration when developing interventions against unhealthy weight and suicidal ideation.

Trends in Health-Risk Behaviors among Chinese Adolescents

Adolescent health-risk behaviors can have long lasting negative effects throughout an individual's life, and cause a major economic and social burden to society. This study aimed to estimate the prevalence of the health-risk behaviors among Chinese adolescents and to test the trends in health-risk behaviors without and with adjusting for sociodemographic characteristics. Data were drawn from the School-based Chinese Adolescents Health Survey, which is an ongoing school-based study about the health-risk behaviors among Chinese adolescents (7th to 12th grade). During the first wave through the third wave, the prevalence of lifetime, past 12-month, and past 30-day use of opioid decreased by 4.19%, 0.63%, and 0.56%, respectively. Moreover, the prevalence of lifetime, past 12-month, and past 30-day sedative use decreased by 3.03%, 0.65%, and 0.35%, respectively. During the three waves, most trends in the prevalence of health-risk behaviors were downward, with a few exceptions: The prevalence of lifetime smoking, drinking, methamphetamine use, and sleep disturbance increased by 7.15%, 13.08%, 0.48%, and 9.06%, respectively. The prevalence of lifetime 3,4-methylene dioxy methamphetamine use (from 0.49% to 0.48%), lifetime mephedrone use (from 0.30% to 0.24%), or suicide attempts (from 2.41% to 2.46%) remained stable.

Leisure-time sedentary behavior and suicide attempt among 126,392 adolescents in 43 countries

BACKGROUND

Adolescent suicide is a major global mental health problem. Exploring variables associated with suicide attempts is important for the development of targeted interventions. The aim of the current study was to explore associations between leisure-time sedentary behavior and suicide attempts.

METHODS

Data from the Global School-based Student Health Survey were analyzed. Data on past 12-month suicide attempts and self-reported leisure-time sedentary time were collected. Multivariable logistic regression and meta-analysis were conducted to assess the associations.

RESULTS

Among 126,392 students from 43 countries (mean age 13.8 ± 0.96 years; 48.9% female), 10.6% had attempted suicide. The prevalence of suicide attempts increased with increasing sedentary leisure-time per day (from 9% at <1 h/day to 16.8% at >8 h/day). Compared to those engaging in <1 h/day sedentary during leisure-time, there was a dose-dependent increase in odds ratios (ORs) for suicide attempts, with the OR for >8 h/day being 1.45 (95% confidence interval=1.19-1.77).

LIMITATIONS

The study is cross-sectional, therefore the directionality of the relationships cannot be deduced.

CONCLUSIONS

Our data suggest that leisure-time sedentary behavior is associated with increased odds for suicide attempt in adolescence. Future longitudinal data are required to confirm/refute the findings to inform public prevention campaigns.

The association between somatic symptoms and suicidal ideation in Chinese first-episode major depressive disorder

BACKGROUND

Somatic symptoms are prevalent in patients with major depressive disorder (MDD) and often associated with a high risk of suicide. However, which somatic symptoms display as significant risk factors for suicidal ideation (SI) is still poorly understood in MDD.

METHODS

Two thousand and seventeen Chinese patients with first-episode MDD from the National Survey on Symptomatology of Depression were included in this study. A doctor-rating assessment questionnaire was constructed to evaluate depression related somatic symptoms, and stepwise logistic regression analysis was performed to explore the relationship between somatic symptoms and SI.

RESULTS

Our results showed a high prevalence of current SI in first-episode MDD (50.87%), while no significant gender differences (53.32% vs. 49.26%, P = 0.076) were observed. In addition, patients who have more somatic symptoms would be at the higher risk to elicit SI, and stepwise logistic regression analysis indicated that age (β = -0.020, P < 0.001), Pre-verbal physical complaints (β = 0.356, P = 0.001), Sensory system complaints (β = 0.707, P = 0.000), Other pain conditions (β = 0.434, P < 0.001), Late insomnia (β = 0.267, P = 0.008), Hypersomnia (β = 0.936, P < 0.001), Weight loss (β = 0.272, P = 0.006), Hyposexuality (β = 0.513, P = P < 0.001) were strongly associated with current SI in first-episode Chinese major depression.

CONCLUSIONS

Somatic symptoms are strongly associated with SI in first-episode MDD. It is suggestive for clinicians to show concerns for patients' somatic symptoms in practice.

Association between problematic Internet use, sleep disturbance, and suicidal behavior in Chinese adolescents

BACKGROUND AND AIMS

This large-scale study aimed to test (a) associations of problematic Internet use (PIU) and sleep disturbance with suicidal ideation and suicide attempts among Chinese adolescents and (b) whether sleep disturbance mediates the association between PIU and suicidal behavior.

METHODS

Data were drawn from the 2017 National School-based Chinese Adolescents Health Survey. A total of 20,895 students' questionnaires were qualified for analysis. The Young's Internet Addiction Test was used to assess PIU, and level of sleep disturbance was measured by the Pittsburgh Sleep Quality Index. Multilevel logistic regression models and path models were utilized in analyses.

RESULTS

Of the total sample, 2,864 (13.7%) reported having suicidal ideation, and 537 (2.6%) reported having suicide attempts. After adjusting for control variables and sleep disturbance, PIU was associated with an increased risk of suicidal ideation (AOR = 1.04, 95% CI = 1.03-1.04) and suicide attempts (AOR = 1.03, 95% CI = 1.02-1.04). Findings of the path models showed that the standardized indirect effects of PIU on suicidal ideation (standardized β estimate = 0.092, 95% CI = 0.082-0.102) and on suicide attempts (standardized β estimate = 0.082, 95% CI = 0.068-0.096) through sleep disturbance were significant. Conversely, sleep disturbance significantly mediated the association of suicidal behavior on PIU.

DISCUSSION AND CONCLUSIONS

There may be a complex transactional association between PIU, sleep disturbance, and suicidal behavior. The estimates of the mediator role of sleep disturbance provide evidence for the current understanding of the mechanism of the association between PIU and suicidal behavior. Possible concomitant treatment services for PIU, sleep disturbance, and suicidal behavior were recommended.

Review: Schlafprobleme und psychische Störungen im Kindes- und Jugendalter

Zusammenfassung. Schlafprobleme und -störungen sind in Kindheit und Jugendalter weitverbreitet. Dieser Review beleuchtet den Zusammenhang zwischen Schlafproblemen und psychischen Störungen im Kindes- und Jugendalter. Schlafprobleme und -störungen gelten zum einen als Risikofaktoren für die Entwicklung psychischer Störungen, aber auch als Symptom und Auswirkung psychischer Störungen. Oft stehen Schlafverhalten und Psychopathologie in einer Wechselwirkung, sodass Schlafprobleme zur Intensität und Aufrechterhaltung psychischer Störungen beitragen. Dieser bidirektionale Zusammenhang ist sowohl in der frühen Kindheit als auch im Schulalter und bei Jugendlichen zu beobachten. Viele Studien konnten zeigen, dass es einen langfristigen Zusammenhang über die kindliche Entwicklung hinweg gibt. Sowohl Umweltfaktoren als auch genetische Faktoren scheinen bei der Entwicklung und Aufrechterhaltung dieses Zusammenhangs eine Rolle zu spielen. Diverse Forschungsergebnisse zeigen, dass die Behandlung von psychischen Störungen und die Behandlung von Schlafproblemen sich wechselseitig positiv beeinflussen. Daher ist die Berücksichtigung von Schlafproblemen in der Diagnostik und Behandlung, aber auch in der Prävention von psychischen Störungen dringend anzuraten.

Sexual minority status and suicidal behaviour among Chinese adolescents: a nationally representative cross-sectional study

OBJECTIVES

Suicidality among sexual minority adolescents has generated worldwide concern in recent decades, and previous Western studies have demonstrated that sexual minority status is associated with adolescent suicidality. However, whether this association exists in Chinese adolescents remains largely unknown. This study aimed to estimate the associations between sexual minority status and suicidal behaviour among Chinese adolescents.

DESIGN

Cross-sectional survey.

SETTING

A total of 506 high schools in 7 provinces of China.

PARTICIPANTS

A total of 150 822 students in grades 7-12 who completed the questionnaires (response rate of 95.9%) were included.

MAIN OUTCOME MEASURES

Suicidal ideation and suicide attempts were used to measure suicidal behaviour, and sexual attraction (opposite sex, same sex or both sex) was used as a measure for sexual minority status.

RESULTS

Of the 150 822 adolescents analysed, 4.1% self-reported as sexual minorities and 17.3% were unsure. Compared with heterosexual and unsure adolescents, same-sex romantic attraction (SSA) and both-sex romantic attraction (BSA) adolescents reported a higher prevalence of past-year suicidal ideation (SSA: 21.6% for males and 30.4% for females; BSA: 34.7% for males and 42.3% for females) and suicide attempts (SSA: 6.9% for males and 8.9% for females; BSA: 12.2% for males and 10.9% for females). After adjustment for covariates, SSA and BSA adolescents were more likely to have past-year suicidal ideation and suicide attempts than their heterosexual and unsure peers. BSA adolescents reported the highest risk of suicidal ideation (males: adjusted OR (AOR) 2.42, 95% CI 2.03 to 2.88; females: AOR 2.61, 95% CI 2.41 to 2.82) and suicide attempts (males: AOR 3.83, 95% CI 2.85 to 5.14; females: AOR 2.59, 95% CI 2.19 to 3.06).

CONCLUSIONS

Our study suggested that Chinese sexual minority adolescents were at increased risk of suicidality, and those with BSA had an especially high risk in this population. These findings emphasised the urgent need to develop targeted interventions to effectively address suicide-related problems among Chinese sexual minority adolescents.

Prevalence, risk factors and clinical characteristics of suicidal ideation in Chinese patients with depression

BACKGROUND

Suicide risk is greatly increased in depression. Detection of those at risk is clinically important. Hence, this study aimed to evaluate the prevalence and identify independent risk factors associated with suicidal ideation (SI) in a widespread symptomatology within and outside DSM framework.

METHODS

This study was part of the National Survey on Symptomatology of Depression (NSSD) which was designed to investigate the magnitude of symptoms of current major depressive episode in China. Stepwise multivariable logistic regression was performed to examine the independent risk factors for SI, including variables that are statistically significant in univariate analysis. Receiver operating characteristic (ROC) was used to evaluate the performance of the regression model.

RESULTS

A total of 3275 patients (1293 males and 1982 females) were included in our analysis. Of these, 1750 patients (53.4%) had SI. Independent risk predictors included crying (P = 0.000; odds ratio = 1.827), helplessness (P = 0.000; odds ratio = 1.514), worthlessness (P = 0.001; odds ratio = 1.359), hopelessness (P = 0.000; odds ratio = 1.805), unusually restless (P = 0.005; odds ratio = 1.276), self-harm (P = 0.000; odds ratio = 3.385), mood-incongruent psychosis (P = 0.000; odds ratio = 2.782), feeling losing control of oneself (P = 0.009; odds ratio = 1.352), hypersomnia (P = 0.000; odds ratio = 1.805), sensory system complaints (P = 0.000; odds ratio = 1.546), derealization (P = 0.006; odds ratio = 1.580), guilt (P = 0.002; odds ratio = 1.332), suicidal attempts (P = 0.000; odds ratio = 2.841), male gender (P = 0.001; odds ratio = 0.756), the total course of depression (P = 0.010; odds ratio = 1.003) in the regression model. In addition, the areas under the curve of the ROC and the accuracy for the regression model were 0.80 and 0.76, respectively.

CONCLUSIONS

This study provided an effective risk model for SI in MDD and indicated that all these factors in our model allow better the employment of preventative measures.

Associations of Childhood Maltreatment with Single and Multiple Suicide Attempts among Older Chinese Adolescents

OBJECTIVES

To test, among older Chinese adolescents, the associations of childhood maltreatment with single and multiple suicide attempts and whether these associations vary in relation to the presence of sleep disturbance.

STUDY DESIGN

We analyzed data collected from 10th to 12th graders from 7 randomly selected provinces of China in the 2015 School-based Chinese Adolescents Health Survey. There were 83 200 students who were invited to participate, and 75 715 students' questionnaires were completed and qualified for the survey. Adjusted multinomial logistic regression models were conducted to evaluate the associations of childhood maltreatment with suicide attempts.

RESULTS

Compared with no suicide attempts, each type of adjusted childhood maltreatment (physical abuse, emotional abuse, sexual abuse, physical neglect, or emotional neglect) was associated with an increased risk of single and multiple suicide attempts (P < .05). The magnitude of the aORs in multiple suicide attempters was greater than those in single suicide attempters. Moreover, the adjusted interaction effects for a single suicide attempt between each type of childhood maltreatment and sleep disturbance were all statistically significant in the multivariable multinomial logistic regression models (P < .001). However, the adjusted interaction effects for multiple suicide attempts were not significant (P > .05).

CONCLUSIONS

Maltreatment during one's childhood is associated with an increased risk of single and multiple suicide attempts among older Chinese adolescents. Sleep disturbances play a moderating role in these associations for a single suicide attempt.