Suicidality as a function of impulsivity, callous-unemotional traits, and depressive symptoms in youth

Utility of Single Items within the Suicidal Behaviors Questionnaire-Revised (SBQ-R): A Bayesian Network Approach and Relative Importance Analysis

The Suicidal Behaviors Questionnaire-Revised (SBQ-R) comprises four content-specific items widely used to assess the history of suicide-related thoughts, plans or attempts, frequency of suicidal ideation, communication of intent to die by suicide and self-reported likelihood of a suicide attempt. Each item focuses on a specific parameter of the suicide-related thoughts and behaviors construct. Past research has primarily focused on the total score. This study used Bayesian network modeling and relative importance analyses on SBQ-R data from 1160 U.S. and 1141 Chinese undergraduate students. The Bayesian network analysis results showed that Item 1 is suitable for identifying other parameters of the suicide-related thoughts and behaviors construct. The results of the relative importance analysis further highlighted the relevancy of each SBQ-R item score when examining evidence for suicide-related thoughts and behaviors. These findings provided empirical support for using the SBQ-R item scores to understand the performances of different suicide-related behavior parameters. Further, they demonstrated the potential value of examining individual item-level responses to offer clinically meaningful insights. To conclude, the SBQ-R allows for the evaluation of each critical suicide-related thought and behavior parameter and the overall suicide risk.

Cumulative ecological risk and nonsuicidal self-injury in adolescents: The mediation of depression and the moderation of impulsiveness

BACKGROUND

This study is based on the biosocial model of nonsuicidal self-injury (NSSI), to explore the effects of cumulative ecological risk on adolescents' NSSI, the mediating effect of depression between cumulative ecological risk and adolescents' NSSI, and the moderating role of impulsiveness in this mediating pathway.

METHODS

A total of 16 508 adolescents, with 7903 males (47.9%), participated in the study and completed the Cumulative Ecological Risk Questionnaire, the Short Form of the Center for Epidemiological Studies Depression Scale, the Impulsiveness assessment, and the Nonsuicidal Self-Injury Scale.

RESULTS

(1) There was a significant positive correlation between cumulative ecological risk, depression, impulsiveness, and NSSI; (2) cumulative ecological risk significantly predicted adolescents' NSSI; (3) depression had a mediating effect between cumulative ecological risk and adolescents' NSSI; and (4) impulsiveness moderated both the effects of cumulative ecological risk on adolescents' depression and NSSI and the effects of depression on NSSI in adolescents.

CONCLUSIONS

Impulsiveness and depression are risk factors for adolescent NSSI and play a crucial role between cumulative ecological risk and NSSI in adolescents.

Negative Parenting Styles and Psychological Crisis in Adolescents: Testing a Moderated Mediating Model of School Connectedness and Self-Esteem

Little is known about how rejecting and controlling parenting styles may influence adolescent psychological crisis and what conditions may buffer the detrimental effects of psychological crisis. By integrating multiple theories, this study investigated self-esteem as an underlying mediator and school connectedness as a potential moderator to explain the link between negative parenting and the two psychological crises among Chinese adolescents. In this study, the questionnaire method is adopted to examine the combined mechanism of rejecting parenting style and controlling parenting style on the psychological crisis of adolescents. In total, 1863 adolescents were involved in this study, ranging from 13 to 17 years old. The results showed that both the rejecting parenting style and the controlling parenting style can significantly and positively predict the level of psychological crisis of adolescents, but the predictive power of the rejecting parenting style was stronger. Self-esteem partially mediates the relationship between rejecting parenting style, controlling parenting style, and psychological crisis. School connectedness moderates both the effects of rejecting parenting styles on self-esteem and the effects of self-esteem on the psychological crisis. This study identifies the internal mechanisms by which negative parenting styles affect adolescents' psychological crisis, and reveals the mediating and moderating roles of self-esteem and school connectedness, providing additional explanatory paths for the mechanisms of adolescents' psychological crisis.

Adolescents in Treatment for Substance Use Disorders: Callous-Unemotional Traits Moderate Associations Between Transdiagnostic Symptoms and Adolescent Suicidality

Suicide, a common cause of death in adolescents, is linked to internalizing and externalizing symptoms. These associations are pronounced amongst adolescents who use substances. But these relationships are complex. For example, sex differences are present in association with internalizing/externalizing symptoms as well as differences in suicidality. A rarely explored factor that may account for this complexity as a moderator is callous-unemotional traits. The present study examines associations of internalizing and externalizing in relation to suicidality in the context of callous-unemotional traits amongst adolescents in substance use treatment. Additionally, sex differences were explored. A sample of 317 adolescents (13-18; 16.05 ± 1.22) in treatment for substance use completed measures for internalizing, externalizing, and suicidal symptoms. The main result suggested the presence of callous-unemotional (CU) traits attenuated the positive association between internalizing and a latent suicidality factor. This novel result contextualizes the association between transdiagnostic symptoms and suicidality. Assessing CU traits in the presence of internalizing symptoms may be an important component of understanding suicide risk amongst adolescents in treatment for substance use.

Racial Differences in Emergency Department Visit Characteristics and Management of Preadolescents at Risk of Suicide

OBJECTIVE

Suicide rates and frequency of pediatric emergency department (ED) visits for suicidal thoughts and behaviors have increased among Black preadolescents in the United States in recent years. This study examined whether characteristics of ED visits and treatment management of preadolescents with suicidal thoughts and behaviors differed by race.

METHODS

An electronic medical record query identified patients ages 8-12 (N=504) who visited a pediatric ED with a psychiatric-related chief complaint in 2019. The authors examined suicidal thoughts and behaviors that were reported with the Ask Suicide-Screening Questions tool, ED clinical impression, and ED disposition overall and by race.

RESULTS

Compared with other racial groups, Black preadolescents were less likely to report suicidal thoughts, despite equivalent lifetime histories of suicide attempts, and were more likely to be brought to the ED by police and discharged (instead of being admitted to inpatient psychiatric care).

CONCLUSIONS

Research to better understand racial disparities in suicide risk among preadolescents can inform prevention efforts.

Externalising Behaviours, Impulsivity, Alexithymia, and Emotional Dysregulation in Adolescents' Suicidality

Objective

suicide represents the second leading cause of death among adolescents (WHO, 2021). A deeper understanding of the characteristics that lead to it is crucial to increase the ability of clinicians in evaluating, treating, and preventing it. The objective of this study is to analyze the differences in impulsivity, externalizing behaviors, emotion dysregulation, and alexithymia between two groups of adolescents, the first presenting suicidal ideation (SI), the second presenting at least one suicide attempt (SA), in an ideation-to-action framework.

Method

we conducted a retrospective study with 190 adolescents (M= 14.5, SD _age = 1.63; SI: n = 97, SA: n = 93). All were hospitalized in the Complex Operative Child Neuropsychiatry Hospital Unit (UOC-NPI) of the Hospital-University of Padua. Data were collected using the Youth Self-Report (YSR 11-18), Barratt's Impulsiveness Scale (BIS-11) and the Toronto Alexithymia Scale (TAS-20) questionnaires.

Results

the SA group obtained higher clinical scores in the YSR "rule-breaking behavior" and "conduct problems" scales, and in total TAS-20.

Conclusions

the role of externalizing problems and alexithymia could open new frontiers in the understanding of suicide. These new data could be useful for the implementation of early screening protocols and for directing clinical interventions, promoting greater emotion regulation and anger management skills among patients.

Suicidality and Personality Pathology in Adolescence: A Systematic Review

This work presents a review of research papers examining the role of emerging personality pathology in suicidal ideation and behaviours in adolescence. Initially, 226 studies were selected in line with PRISMA guidelines, and 33 articles were finally included in this review. The data show percentages of any personality disorder diagnosis ranging from 19.5 to 22.8% in suicide attempters, while in autopsy studies, the rate of personality disorder diagnosis varied between 29.6 and 42.1%. The overwhelming majority of the studies focus on the role of borderline personality disorder (BPD) in suicidal behaviours, also highlighting its predictive role at a longitudinal level. Furthermore, the literature review shows that personality traits supposed to underlie BPD, such as affective instability, impulsivity and identity diffusion, have specific predictive links with suicidal conduct. Other personality pathology dimensions, such as aggressiveness, sadism and perfectionism that are associated with other personality disorders, namely, antisocial and narcissistic personality disorders, have also shown a significant mediating role for suicidal risk. Overall, these results seem to parallel the role of personality pathology in predicting suicide in adulthood and point to the relevance of assessing the presence of emerging patterns of personality disorders for the clinical management of suicidal risk in adolescence.

Impulsiveness indirectly affects suicidal ideation through depression and simultaneously moderates the indirect effect: A moderated mediation path model

OBJECTIVE

This study aims to investigate the indirect effect of impulsiveness on suicidal ideation through depression and the moderating effect of impulsiveness on the indirect effect in an integrated path model.

METHODS

Self-rating depression scale (SDS), Barratt impulsiveness scale-11th version (BIS-11), and self-rating idea of suicide scale (SIOSS) were applied. A moderated mediation path model was established including impulsiveness, depression, and suicidal ideation as observed variables.

RESULTS

The main results revealed that the moderated mediation path model fit well in describing the relationships among impulsiveness, depression, and suicidal ideation. The indirect effect of impulsiveness mediated by depression and the moderating effect of impulsiveness on suicidal ideation was significant. Multiple comparisons showed that the indirect effects under different conditions of impulsiveness had statistical differences. The higher the impulsiveness was, the stronger the predictive effect of depression on suicidal ideation was.

CONCLUSIONS

The present study confirms that people who have impulsive traits are riskier to generate suicidal thoughts because they are more likely to suffer from depression and that people who are depressive have even higher risk to develop suicidal thoughts when they simultaneously have impulsive traits. In clinical and health care work, when considering depression to prevent suicidal ideation, impulsiveness needs to be monitored throughout the process of premorbid and onset stages of depression.

Psychopathy

Psychopathy is a personality disorder characterized by a constellation of affective, interpersonal, lifestyle and antisocial features whose antecedents can be identified in a subgroup of young people showing severe antisocial behaviour. The prevalence of psychopathy in the general population is thought to be ~1%, but is up to 25% in prisoners. The aetiology of psychopathy is complex, with contributions of both genetic and environmental risk factors, and gene-environment interactions and correlations. Psychopathy is characterized by structural and functional brain abnormalities in cortical (such as the prefrontal and insular cortices) and subcortical (for example, the amygdala and striatum) regions leading to neurocognitive disruption in emotional responsiveness, reinforcement-based decision-making and attention. Although no effective treatment exists for adults with psychopathy, preliminary intervention studies targeting key neurocognitive disturbances have shown promising results. Given that psychopathy is often comorbid with other psychiatric disorders and increases the risk of physical health problems, educational and employment failure, accidents and criminality, the identification of children and young people at risk for this personality disorder and preventative work are important. Indeed, interventions that target the antecedents of psychopathic features in children and adolescents have been found to be effective.

The Study of Motivation in the Suicidal Process: The Motivational Interview for Suicidality

Introduction: Suicide is the outcome of a process starting with the experiences of an unbearable pain or hopelessness, passing from suicidal ideation and planning, to possible para-suicidal behaviors or actual attempts. Recent studies have evidenced the necessity to integrate approaches based on the identification of psychopathological diagnoses and other variables as possible predictors of suicidal conduct with a more clinically based approach. A clinical assessment is needed that focuses on the patients' mental state with respect to thoughts concerning death and suicide. In particular, a qualitative assessment of motivations underlying the suicidal process could represent an effective guide for clinicians engaged in the difficult field of preventing adolescents' suicidal gestures. Most instruments investigating the suicidal motivation are self-report measures, possibly resulting in a lack of sufficiently valid assessment of this area. In the present work, we present the Motivational Interview for Suicidality in Adolescence (MIS-A) aiming at identifying the motivational areas sustaining suicidal ideation and gestures in this phase of development. Materials and Methods: The identification of the different areas derives from a thorough review of the empirical literature subsequently vetted by expert clinicians who selected specific reasons behind suicidal ideation and gesture. Result: The MIS is a semi-structured clinician-report interview. The interview is composed of seven areas and 14 sub-areas, evaluated on a four-point Likert scale: illness motivated attempts area, chronic presence of internal pessimistic criticism area, sense of defeat and entrapment area, relational area, external motivated crisis area, extreme and unusual cases area, and lack of control area. Conclusions: The path followed in the creation of the MIS reflects both an empirically orientated and a clinically informed approach. Creating this MIS is the first step within a wider research project that will allow one to test the reliability of the instrument.

Nucleus Accumbens Fast-Spiking Interneurons Constrain Impulsive Action

BACKGROUND

The nucleus accumbens (NAc) controls multiple facets of impulsivity but is a heterogeneous brain region with diverse microcircuitry. Prior literature links impulsive behavior in rodents to gamma-aminobutyric acid signaling in the NAc. Here, we studied the regulation of impulsive behavior by fast-spiking interneurons (FSIs), a strong source of gamma-aminobutyric acid-mediated synaptic inhibition in the NAc.

METHODS

Male and female transgenic mice expressing Cre recombinase in FSIs allowed us to identify these sparsely distributed cells in the NAc. We used a 5-choice serial reaction time task to measure both impulsive action and sustained attention. During the 5-choice serial reaction time task, we monitored FSI activity with fiber photometry calcium imaging and manipulated FSI activity with chemogenetic and optogenetic methodology. We used electrophysiology, optogenetics, and fluorescent in situ hybridization to confirm these methods were robust and specific to FSIs.

RESULTS

In mice performing the 5-choice serial reaction time task, NAc FSIs showed sustained activity on trials ending with correct responses, but FSI activity declined over time on trials ending with premature responses. The number of premature responses increased significantly after sustained chemogenetic inhibition or temporally delimited optogenetic inhibition of NAc FSIs, without any changes in response latencies or general locomotor activity.

CONCLUSIONS

These experiments provide strong evidence that NAc FSIs constrain impulsive actions, most likely through gamma-aminobutyric acid-mediated synaptic inhibition of medium spiny projection neurons. Our findings may provide insight into the pathophysiology of disorders associated with impulsivity and may inform the development of circuit-based therapeutic interventions.

Psychopathic Traits, Pubertal Timing, & Mental Health Functioning in Justice-Involved Adolescents

Although psychopathic traits and pubertal timing have garnered a great deal of attention as potent risk factors for antisocial trajectories, very little research has examined how these processes may be related. We investigated whether psychopathic traits were related to deviations in pubertal onset in a clinically-relevant sample of youth detained in juvenile detention facilities. One-hundred and thirty-seven adolescents (ages 12-17) completed surveys of pubertal timing, psychopathic traits, and mental health functioning. As predicted, psychopathic traits were found to be associated with pubertal timing, and the psychopathy facets evidenced differential associations with the onset of puberty. Trait disinhibition was associated with relatively earlier pubertal timing, whereas trait boldness appeared to confer protection against early pubertal onset in this sample. Symptoms of alcohol/ substance use and anger/ irritability were positively related to psychopathic traits, but only among youth who reported average-/late-pubertal development. These findings implicate psychopathic personality traits as individual difference variables that may influence the onset of pubertal timing and interact with pubertal timing to place justice-involved youth at risk for poor mental health.

Clinical risk factors among youth at high risk for suicide in South Africa and Guyana

INTRODUCTION

Suicide is the second leading cause of death among youth worldwide, but low- and middle-income countries (LMICs) account for 78% of all suicides. The LMICs South Africa and Guyana rank high in the global suicide rates. To better understand and prevent suicide among the youth, the present study targets youths at high risk for suicide, in an LMIC, to contextually and representatively identify clinical risk factors for suicide.

METHODS

One hundred-ninety youths, aged 11-21, separated from biological parents at the time of assessment, in South Africa and Guyana, were administered the Child Behavior Checklist and Behavior Assessment System for Children to assess clinical symptoms. The youths were asked about current suicide ideation and previous attempt(s). Self-report responses to clinical items yielded scale scores for depression, social stress, atypicality, somatization, anxiety, and ADHD. Using an integrative data analytic technique, clinical scale scores were standardized and used to predict suicidal behaviors in a binary logistic regression analysis.

RESULTS

Approximately 22% of Black South African youths and 60% of Guyanese youths endorsed suicide ideation and attempt or suicide attempt only. In fully adjusted analyses, the odds of atypicality and somatization were 1.96 and 1.67 times greater among the youths who endorsed suicidal ideation when compared with those who did not (p < .04). Youth social stress was significantly associated with the suicide attempt, controlling for model covariates (odds ratio [OR], 1.88, p = .05). Gender moderated the effect of somatization on youth suicide.

CONCLUSION

Our results contextualize how social stress, atypicality, and somatization relate to LMIC youth suicide. Further study on high-risk samples will contribute to generalizable suicide-prevention models.

Psychopathy and Suicidal Thoughts and Behaviors Revisited: Results From a Statewide Population of Institutionalized Youth

Suicide is the leading cause of death for incarcerated youth, and up to half of all juveniles in confinement experience suicidal ideation in addition to other psychopathology, including psychopathic personality features. Unfortunately, limited research has investigated the psychopathy-suicidality link among juvenile delinquents and using newer psychopathy measures. Based upon a statewide population of incarcerated juvenile offenders, we found that psychopathy was a significant risk factor for suicidal ideation and lifetime suicide attempts, but the latter relationship was attenuated by lifetime depression diagnosis. In addition, certain affective psychopathic features such as Stress Immunity conferred protection against suicidality, whereas behavioral and lifestyle components including Carefree Nonplanfulness, Blame Externalization, and Rebellious Nonconformity were positively linked to suicidal thoughts among the youth offenders. As these risk factors are routinely screened for in juvenile justice settings, this study's findings have considerable implications to applied practice and prevention among juvenile justice involved youth.

Association between anxiety and aggression in adolescents: a cross-sectional study

Background

The purpose of this study was to investigate the relationship between anxiety proneness and aggressive behavior in adolescents.

Methods

A quantitative, large scale cross-sectional study was conducted in Korea. The survey questionnaire included general health behavior and scales for assessing anxiety (Revised Children’s Manifest Anxiety Scale; RCMAS) and aggressive behavior (The Aggression Questionnaire; AQ) in adolescents.

Results

A total of 2432 students participated in the survey, and 1933 individuals completed the questionnaire, indicating a response rate of 79.5%. Based on RCMAS, 163 (8.4%) subjects were classified as the anxiety group. Aggressive behavior was significantly associated with higher anxiety scores. In particular, among four subdomains of aggression, anger and hostility had a stronger relationship with anxiety than did physical and verbal aggression. Multivariate analysis demonstrated that anxiety was independently associated with gender, age, headache, constipation, asthma, and aggression score. Adolescents with total aggression scores of 69 or higher showed a 9-fold (AOR = 9.00, CI = 6.33–13.51) higher risk of anxiety compared to those with under 69.

Conclusion

Aggression and anxiety are important aspects of mental health in adolescents. Our results demonstrated that higher risk of anxiety was associated with total aggression scores. In particular, indirect aggression (i.e. anger and hostility) was more closely associated with anxiety than direct aggression.

Subtypes of suicidal ideation in Korean adolescents: A multilevel latent profile analysis

OBJECTIVE

This study intended to classify subtypes of Korean adolescents with suicidal ideation based on mental health problems and to explore the relationship between such subtypes and individual-, school- and community-level factors.

METHOD

Data from high school freshmen who participated in the 2013 school-based mental health screening test and data about school and community variables obtained from public sources were combined and analyzed. A multilevel latent profile analysis using mental health issues as class indicators that included several predictors was conducted.

RESULTS

Three latent profiles were identified: Group 1 (6.5%) had high scores for both the internalizing and externalizing problems; Group 2 (40.2%) had high scores for internalizing problems, such as depression and mood related symptoms; and Group 3 (53.3%) had lower scores for all mental health problems compared to Groups 1 and 2. Gender, peer conflict, family conflict and academic problems were significant predictors at the individual level; school dropout rate was a significant school-level variable; and percent of youth in the total population, availability of mental health services, number of social welfare facilities and percentage of the total budget devoted to education/welfare were significant community-level variables.

CONCLUSION

The present findings suggest that adolescents with suicidal ideation can be classified into several distinct subtypes based on mental health problems. These profiles and their associated covariates will aid in the establishment of youth suicide prevention policies.

Psychopathic personality traits as a form of dispositional capability for suicide

The capability to enact lethal self-harm has recently been highlighted as a critical risk factor for suicidal behavior. Klonsky and May's (2015) three step theory of suicide (3ST) expanded upon the construct of the capability for suicide by dividing it into categories: dispositional, acquired, and practical. The current study examined constructs of Patrick and colleagues' (2009) triarchic model of psychopathy as indicators of dispositional capability in gun owners, a sample at heightened risk for death by suicide (Anestis and Houtsma, 2017). We anticipated that specific psychopathic traits would exhibit robust associations with other components of the capability for suicide. In a sample of 300 gun-owning adults, Boldness was uniquely related to all indicators of practical capability in both male and female gun owners, and a Boldness*Meanness interaction predicted the highest levels of some capability components. These results are consistent with theoretical conceptualizations of the triarchic model. Our findings indicate that, among US gun owners, dispositional factors may impact comfort with and aptitude with guns, which may enhance our understanding of which gun owners are at the greatest risk of gun suicide should they develop suicidal thoughts.

Association of Self-reported Impulsivity to Nonsuicidal Self-Injury, Suicidality, and Mortality in Adolescent Psychiatric Inpatients

This study examines the association of self-reported impulsivity to nonsuicidal self-injury, suicidal ideation, suicide attempts, and completed suicides in a clinical sample of 508 Finnish adolescents (aged 12-17) treated in psychiatric inpatient care between April 2001 and March 2006. The Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime interview was used to gather information on psychiatric disorders, impulsivity, and suicidality of the adolescents. Mortality data were obtained from the national cause of death register. In adolescent girls, impulsivity was significantly associated with suicidal ideation and attempts and completed suicides in adolescent boys. Of adolescent boys with impulsivity, 10.4% had died by suicide during the follow-up time. For preventive purposes, health care professionals are encouraged asked adolescents targeted questions about impulsivity and to consider the associated risk of suicidality identified in this study.

Self-rated psychopathic traits in a sample of treatment-seeking adolescent girls with internalizing and externalizing disorders: comparisons to girls in the community

BACKGROUND

Psychopathy research has thus far focused mostly on child, male, and delinquent samples, but the results are most likely non-generalizable to adolescent girls with mental health disorders.

AIM

The present study aimed to compare self-rated psychopathic traits between female psychiatric outpatients and girls in the community, and to investigate how psychopathic traits relate to psychiatric disorders.

METHOD

The outpatient sample comprised 163 girls aged 15-17-years recruited from municipal mental health services. Psychiatric diagnoses were assessed based on the ICD-10 classification. The community sample comprised 355 girls from secondary, vocational, and high schools. The Youth Psychopathic trait Inventory (YPI) served as a self-assessment tool.

RESULTS

Treatment-seeking girls exhibit a more impulsive and irresponsible lifestyle than do girls in the community. Girls with externalizing psychopathology, unlike those with an internalizing disorder, exhibit more deficient affective experience than do girls in the community. Psychopathic traits associate with having a psychiatric disorder, a depressive disorder, ADHD, and a conduct disorder.

CONCLUSIONS

The psychiatric examination of treatment-seeking adolescent girls would likely benefit from screening for psychopathy and its underlying components.

Suicide in Elementary School-Aged Children and Early Adolescents

BACKGROUND AND OBJECTIVES

Suicide in elementary school-aged children is not well studied, despite a recent increase in the suicide rate among US black children. The objectives of this study were to describe characteristics and precipitating circumstances of suicide in elementary school-aged children relative to early adolescent decedents and identify potential within-group racial differences.

METHODS

We analyzed National Violent Death Reporting System (NVDRS) surveillance data capturing suicide deaths from 2003 to 2012 for 17 US states. Participants included all suicide decedents aged 5 to 14 years (N = 693). Age group comparisons (5-11 years and 12-14 years) were conducted by using the χ² test or Fisher's exact test, as appropriate.

RESULTS

Compared with early adolescents who died by suicide, children who died by suicide were more commonly male, black, died by hanging/strangulation/suffocation, and died at home. Children who died by suicide more often experienced relationship problems with family members/friends (60.3% vs 46.0%; P = .02) and less often experienced boyfriend/girlfriend problems (0% vs 16.0%; P < .001) or left a suicide note (7.7% vs 30.2%; P < .001). Among suicide decedents with known mental health problems (n = 210), childhood decedents more often experienced attention-deficit disorder with or without hyperactivity (59.3% vs 29.0%; P = .002) and less often experienced depression/dysthymia (33.3% vs 65.6%; P = .001) compared with early adolescent decedents.

CONCLUSIONS

These findings raise questions about impulsive responding to psychosocial adversity in younger suicide decedents, and they suggest a need for both common and developmentally-specific suicide prevention strategies during the elementary school-aged and early adolescent years. Further research should investigate factors associated with the recent increase in suicide rates among black children.

Personality differences in early versus late suicide attempters

BACKGROUND

Suicidality is an individual behaviour caused by a complex framework of internal and external factors. The predictive values of personality traits for a suicide attempt have been demonstrated, especially in conjunction with Cloninger's TCI and impulsivity. Two issues remain unsolved, namely whether these traits alter over time after a suicide attempt, and how they may be influenced by depressive symptoms.

METHODS

We studied two patient cohorts: one sample of 81 patients after a suicide attempt no longer than 3 months previously (SA early) and another sample of 32 patients whose attempt had taken place more than 6 months previously (SA late). We carried out structured interviews with these subjects addressing diagnosis (MINI), suicidality (Scale for suicide ideation), depression (HAMD-17), temperament and character inventory (TCI), and impulsivity (BIS-10). Data analysis was done using SPSS 16.0.

RESULTS

Our two groups did not differ significantly in sociodemographics or suicidality. However, patients in the SA early group were significantly more depressed (p < 0.001), and scored lower in reward dependence (p < 0.001) and persistence (p = 0.005) but higher in harm avoidance (p < 0.001); they did not differ significantly in impulsivity (p < 0.01). Reward dependence, persistence, and harm avoidance remained significantly different between the two groups after controlling for depressive symptoms.

CONCLUSIONS

Our findings suggest that some personality traits vary after a suicide attempt. Further investigations are necessary to verify our results, ideally in longitudinal studies with larger, carefully-described cohorts. It would be also clinically important to investigate the influence of therapeutic strategies on the variability of personality traits and their impact on suicidal behavior.

Understanding the Relationship Between Suicidality and Psychopathy: An Examination of the Interpersonal-Psychological Theory of Suicidal Behavior

A number of studies have reported a bifurcated relationship between psychopathy and suicidality, such that suicidality is positively related to Factor 2 (impulsive-antisocial lifestyle) of psychopathy but negatively related or unrelated to Factor 1 (affective-interpersonal deficits). The present study aims to expand these findings by investigating this relationship through the lens of the interpersonal-psychological theory of suicidal behavior across both undergraduate and forensic samples. We hypothesized that, although both Factors 1 and 2 would be associated with the acquired capability for suicide, Factor 2 would exhibit a unique relationship with suicidal desire (perceived burdensomeness and thwarted belongingness). Results were largely supportive of these hypotheses, although differences were noted across samples and measures. Findings highlight the importance of precision in the assessment of antisociality and suggest potential differences in the construct of psychopathy between non-criminal and criminal samples.

Adolescent Gender Differences in Residential Versus Outpatient Mental Health Treatment: A Meta-Analysis

Level-of-care decisions for adolescents in need of mental health services have been found to be inconsistent. This study sought to establish a research base for more objective and reliable level-of-care decisions related to gender differences in clinical characteristics of male and female patients aged 12–19 years receiving mental health treatment in a residential setting or outpatient mental health services. A meta-analytic approach was used to analyze 20 studies and 49 independent effect sizes across six constructs: internalizing, externalizing, psychosocial stressors, risk to self and others, total pathology, and substance use. The results indicated that male participants had higher levels of externalizing at the outpatient level, and female participants had higher levels of all remaining constructs at both levels of care. This indicated that female patients often presented to both levels of care with greater psychopathology.

Suicidal Tendency Among Adolescents With Adjustment Disorder

Abstract. Background: Adolescents with adjustment disorder (AD) are at risk of presenting suicidal symptoms. Certain personality traits are linked to suicidal tendencies. There is a lack of information about the link between suicide and personality patterns in adolescents with AD. Aims: To identify the personality characteristics that predispose to or prevent the development of suicidal ideation and behavior among adolescents with AD. Method: We recruited 108 adolescents with AD at a public mental health center near Barcelona (Spain). They were administered the Inventario de Riesgo Suicida para Adolescentes (IRIS) to assess suicidal symptoms, as well as the Millon Adolescent Clinical Inventory (MACI) and the 16PF Adolescent Personality Questionnaire (16PF-APQ) to appraise personality features. Results: Doleful personality emerged as the principal risk for suicidal symptoms. The conforming personality pattern exerted a protective effect, and emotional stability was associated with low levels of suicidal tendencies. Among the Big Five factors, anxiety had the highest explanatory power for suicidal tendencies. Conclusion: Certain personality characteristics are associated with heightened or reduced risk of suicidal tendencies in adolescents with AD. Their identification is important for clinicians designing treatment programs for these patients.

Separate and interactive contributions of weak inhibitory control and threat sensitivity to prediction of suicide risk

Biobehavioral dispositions can serve as valuable referents for biologically oriented research on core processes with relevance to many psychiatric conditions. The present study examined two such dispositional variables-weak response inhibition (or disinhibition; INH-) and threat sensitivity (or fearfulness; THT+)-as predictors of the serious transdiagnostic problem of suicide risk in two samples: male and female outpatients from a U.S. clinic (N=1078), and a population-based male military cohort from Finland (N=3855). INH- and THT+ were operationalized through scores on scale measures of disinhibition and fear/fearlessness, known to be related to DSM-defined clinical conditions and brain biomarkers. Suicide risk was assessed by clinician ratings (clinic sample) and questionnaires (both samples). Across samples and alternative suicide indices, INH- and THT+ each contributed uniquely to prediction of suicide risk-beyond internalizing and externalizing problems in the case of the clinic sample where diagnostic data were available. Further, in both samples, INH- and THT+ interactively predicted suicide risk, with individuals scoring concurrently high on both dispositions exhibiting markedly augmented risk. Findings demonstrate that dispositional constructs of INH- and THT+ are predictive of suicide risk, and hold potential as referents for biological research on suicidal behavior.

Frequency and correlates of suicidal ideation in pediatric obsessive-compulsive disorder

This study examined the frequency and sociodemographic and clinical correlates of suicidal ideation in a sample of children and adolescents with obsessive-compulsive disorder (OCD). Fifty-four youth with OCD and their parent(s) were administered the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime, Children's Yale-Brown Obsessive Compulsive Scale, and Children's Depression Rating Scale-Revised. Children completed the Suicidal Ideation Questionnaire-Junior (SIQ-JR), Child Obsessive Compulsive Impact Scale-Child, and Multidimensional Anxiety Scale for Children; parents completed the Child Obsessive Compulsive Impact Scale-Parent, Swanson, Nolan, and Pelham-IV Parent Scale, and Young Mania Rating Scale-Parent Version. Seven youth endorsed clinically significant levels of suicidal ideation on the SIQ-JR. Suicidal ideation was significantly related to clinician-rated depressive symptoms, age, child-rated impairment and anxiety symptoms, and symmetry, sexuality/religiosity and miscellaneous symptom dimensions. There was no significant association between suicidal ideation and obsessive-compulsive symptom severity, comorbidity patterns, or several parent-rated indices (e.g., impairment, impulsivity). These results provide initial information regarding the frequency and correlates of suicidal ideation in treatment-seeking youth with OCD. Clinical implications are discussed, as well as directions for future research.

The phenomenology and clinical correlates of suicidal thoughts and behaviors in youth with autism spectrum disorders

This study investigated the phenomenology and clinical correlates of suicidal thoughts and behaviors in youth with ASD (N = 102; range 7-16 years). The presence of suicidal thoughts and behavior was assessed through the Anxiety Disorders Interview Schedule-Child and Parent Versions. Children and parents completed measures of anxiety severity, functional impairment, and behavioral and emotional problems. Approximately 11 % of youth displayed suicidal thoughts and behaviors. Children with autism were more likely to have suicidal thoughts and behaviors whereas children with Asperger's disorder were less likely. Suicidal thoughts and behaviors were associated with the presence of depression and post-traumatic stress disorder. Overall, results suggest that suicidal thoughts and behaviors are common in youth with ASD, and may be related to depression and trauma.

'Plue plun' male, 'kath klei' female: gender differences in suicidal behavior as expressed by young people in Cambodia

Few studies from low- and middle-income countries use qualitative methodology to explore suicidal behavior among young people. In Cambodia, young people face the challenge of rapidly changing times and are vulnerable for suicidal behavior as revealed by research in transitional economies. This study seeks to gain a deeper understanding of the suicidal phenomena from a gender, psychosocial and cultural perspective. Six focus-group discussions were conducted among boys and girls, aged 15-19 years, in two secondary schools in a suburban area close to Phnom Penh, the capital city. The data was analyzed using thematic analysis approach. The participants highlighted the gender difference in suicidal behavior by describing the suicide-prone, acting-out male as 'plue plun', while suicide-prone females were described as caught in constricted, tunneled-thinking behavior, expressed as 'kath klei'. Parental attitude and family environment were also pointed out as the chief causes of discontent and there was a strong wish on the part of young people to find space for modern values within the traditional family. The young people's awareness of their challenges in everyday life suggests that school-based programs to prevent suicidal behavior ought to be gender-sensitive and peer-focused.

Injection drug use is associated with suicide attempts but not ideation or plans in a sample of adolescents with depressive symptoms

OBJECTIVE

Based on the interpersonal theory of suicide, pain habituation that occurs with injection substance use may raise risk for a suicide attempt. The current study tested whether injection substance use, relative to painless routes of substance administration, was related to greater risk for suicide attempts. We also assessed whether this risk was specific to suicide attempts and not suicidal ideation or suicide plans.

METHODS

Data on 2095 substance-using adolescents aged 12-17 who endorsed clinically significant depression symptoms and answered questions on suicidal thoughts and behavior were drawn from the 2004-2011 National Survey on Drug Use and Health, a nationally representative household survey. Logistic regression analyses were conducted to assess the associations between injection substance use and suicidal ideation, plans, and attempts.

RESULTS

Injection substance use was associated with suicide attempts (OR = 3.02, 95% CI = 1.75-5.23) but not ideation or plans. These findings were not accounted for by sex, age, race/ethnicity, family income, abuse and dependence symptoms, and depression symptoms. Among ideators, injection substance use was associated with suicide attempts (OR = 2.92, 95% CI = 1.58-5.06), but not plans. Among suicide planners, injection substance use was associated with suicide attempts (OR = 5.16, 95% CI = 1.88-14.17).

CONCLUSION

Consistent with the interpersonal theory of suicide, adolescent injection drug use was associated with specific risk for suicide attempts but not ideation or planning. Hence, consideration of the manner in which adolescents use substances is important in evaluating suicide risk in this population.

Reconsidering the link between impulsivity and suicidal behavior

It is widely accepted that suicidal behavior often occurs with little planning. We propose, however, that suicidal behavior is rarely if ever impulsive-that it is too frightening and physically distressing to engage in without forethought-and that suicidal behavior in impulsive individuals is accounted for by painful and fearsome behaviors capable of enhancing their capacity for suicide. We conducted a meta-analysis of the association between trait impulsivity and suicidal behavior and a critical review of research considering the impulsiveness of specific suicide attempts. Meta-analytic results suggest the relationship between trait impulsivity and suicidal behavior is small. Furthermore, studies examining a mediating role of painful and provocative behaviors have uniformly supported our model. Results from our review suggest that researchers have been unable to adequately measure impulsivity of attempts and that measures sensitive to episodic planning must be developed to further our understanding of this phenomenon.

Outcome of a school-based intervention to promote life-skills among young people in Cambodia

BACKGROUND

Most of the school-based interventions to prevent suicide are from high income countries and there is a need for evidence based interventions in resource-poor settings. The aim of this study is to evaluate the outcome of a school based intervention to reduce risk factors for suicide among young people in Cambodia by promoting life skills.

METHOD

Six classes were randomly selected from two schools each, one designated as experimental and the other as control school, respectively. In experimental school 168 young people (M=92, F=76) received 6 sessions of life skills education and in the control school 131 students (M=53, F=78) received three general sessions on health. We looked at the pre-post differences on Life-Skills Development Scale Adolescent Form (LSDS-AF)- and Youth Self-Report (YSR) questionnaire to measure the effect size (ES) from the intervention after 6 months. We analyzed the data by stratifying for gender and for those who reported more severe suicidal expressions at baseline (high-risk group).

RESULTS

The girls showed improvement in Human Relationship (ES=0.57), Health Maintenance (ES=0.20) and the Total Life Skills Dimensions (ES=0.24), whereas boys with high-risk behavior improved on Human Relationship (ES=0.48), Purpose in Life (ES=0.26) and Total Life Skills Dimensions (ES=0.22). Effect size for YSR-syndrome scores among all individuals showed no improvement for either gender. Among high-risk individuals boys had a small to moderate effect size from intervention on Withdrawn/Depressed (ES=0.40), Attention problems (ES=0.46), Rule breaking behavior (ES=0.36), Aggressive behavior (ES=0.48) and Externalizing syndrome (ES=0.64).

CONCLUSION

Promoting life skills in schools may enhance the overall mental health of young people, indirectly influencing suicide, particularly among boys with high-risk behavior in Cambodia.

Impulsivity, risk taking, and cortisol reactivity as a function of psychosocial stress and personality in adolescents

Although adolescence is characterized by hormonal changes and increased disinhibited behaviors, explanations for these developmental changes that include personality and environmental factors have not been fully elucidated. We examined the interactions between psychosocial stress and the traits of negative emotionality and constraint on impulsive and risk-taking behaviors as well as salivary cortisol reactivity in 88 adolescents. In terms of behavioral outcomes, analyses revealed that negative emotionality and constraint were protective of impulsivity and risk taking, respectively, for adolescents in the no-stress condition; personality did not relate to either behavior in the stress condition. Low-constraint adolescents in the stress condition engaged in less risk taking than low-constraint adolescents in the no-stress condition, whereas there was no effect of stress group for high-constraint adolescents. In terms of cortisol reactivity, analyses revealed that low-constraint adolescents in the stress condition exhibited greater cortisol reactivity compared to high-constraint adolescents, which suggests that low-constraint adolescents mobilize greater resources (e.g., increased cognitive control, heightened attention to threat) in stressful situations relative to nonstressful ones. These results demonstrate that two facets of disinhibition and cortisol reactivity are differentially affected by psychosocial stress and personality (and their interactions) in adolescents.

Reactive/proactive aggression and the development of internalizing problems in males: the moderating effect of parent and peer relationships

The current study examined whether reactive and/or proactive aggression in adolescent males prospectively predicted increased levels of internalizing symptoms (depression and anxiety) in late adolescence. It was postulated that reactive aggression would be robustly related to later internalizing problems, but only among adolescent males who had problematic family or peer social relationships. Participants were a racially diverse group of 289 adolescent males (Mean age = 16). Measures of reactive and proactive aggression, peer rejection, and poor parent-adolescent communication were examined as predictors of both depression and anxiety symptoms assessed approximately 3 years later. The interactive effects between the two facets of aggression and measures of peer rejection and poor parent-adolescent communication in predicting internalizing problems was also examined. Adolescents with high levels of reactive aggression were more likely to exhibit elevated internalizing problems during late adolescence, even when controlling for pre-existing levels of anxiety/depression. However, this association only emerged for adolescents who had high levels of peer rejection and/or poor communication with their parent. Consistent with expectations, proactive aggression was unrelated to internalizing symptoms regardless of social relationship quality. Adolescent reactive, but not proactive, aggression is a risk factor for the development of internalizing problems. However, the findings suggest that interventions designed to foster positive social relationships among reactively aggressive youth may help protect them from developing significant internalizing problems over time.

Evaluation of the validity of the Multidimensional Personality Questionnaire-Simplified-Wording Form (MPQ-SF) in adolescents with treatment histories

The Multidimensional Personality Questionnaire (MPQ) is a widely used personality assessment instrument informing lower- and higher-order personality dimensions. Despite recent developments of brief (MPQ-BF) and simplified wording (MPQ-SF) forms, there is relatively little work on the utility and validity of the MPQ in younger samples with lower reading levels. This study is the first to assess the reliability, factor structure, and criterion validity of the MPQ-SF in a sample of treatment-referred mid-adolescents (N = 105; 12-17 years). Results suggest adequate reliabilities for most of the lower-order primary scales and support a three-factor structure of the MPQ-SF, consistent with previous research with adult and college-aged samples. However, there were also notable cross-loadings for particular scales, which we discuss in relation to the four-factor MPQ model and the Five Factor Model of Personality. Relationships between MPQ personality dimensions and psychopathology using youth, parent, and clinician-rated psychopathology indices supported criterion-related validity. Together, these results confirm the utility of the MPQ in youth with treatment histories.

Is there an empirical link between impulsivity and suicidality in bipolar disorders? A review of the current literature and the potential psychological implications of the relationship

OBJECTIVES

Suicide is highly prevalent among individuals with bipolar disorder and understanding the factors that increase risk for suicide may help to develop targeted interventions to prevent attempts. Impulsivity is thought to be an influential factor associated with suicidality and is also discussed as a key construct of bipolar disorder. The aim of this paper was to systematically review the current evidence to examine the association between impulsivity and suicidality in bipolar disorder.

METHODS

PsycInfo, Medline, and Web of Knowledge databases were searched for articles published up until March 2012. Papers were included if they assessed an adult sample of individuals with bipolar disorders, focused on suicidality (ideation with intent to die, suicide attempts, or completion), and used a validated measure to determine impulsivity.

RESULT

Sixteen papers were identified. Contrary to widespread belief, we found (i) a very inconsistent picture of results including positive, negative, and insignificant associations between impulsivity and suicidality; and (ii) some studies do not take into account important aspects such as state-trait or measurement issues.

CONCLUSIONS

The link between suicidality and impulsivity is less straightforward than often assumed. Drawing clear conclusions about the association is hampered by factors such as inconsistencies in defining suicidality, measuring impulsivity, and differentiating between impulsivity as a personality trait and impulsivity as a state (e.g., a consequence of substance use or premeditation of the attempt). We suggest that the association is less direct and that psychological models (e.g., Joiner's theory of suicidality) can help foster a more in-depth understanding regarding the relationship.

Investigating the roles of different monoamine transmitters and impulse control using the 5-choice serial reaction time task

Previous studies have shown that drugs which block the reuptake of catecholamine neurotransmitters improve impulse control in diseases such as attention deficit hyperactivity disorder (ADHD). Serotonin-specific reuptake inhibitors (SSRI) lack efficacy in ADHD and have been linked to increased suicide risk. The present study investigated drugs with affinity for one or more of the monoamine reuptake transporters using the 5-choice serial reaction time task, a model of attention and impulsivity in rodents. We also tested the effects of the alpha(2)-adreoceptor antagonist, idazoxan and novel antidepressant, agomelatine, which both increase cortical noradrenaline concentrations through non-reuptake mechanisms. Improvements in impulse control were observed with venlafaxine, a serotonin and noradrenaline re-uptake inhibitor (SNRI) but not bupropion (dopamine and noradrenaline re-uptake inhibitor). Sibutramine (SNRI) reduced premature responses by ~50% at the highest dose tested but this was not significant. All three of the SSRIs tested reduced premature responding in a dose-dependent manner, although also slowed response and collection latencies. Neither idazoxan nor agomelatine significantly reduced premature responding, suggesting a lack of efficacy at the doses tested. None of the drugs tested improved attention in this task but sibutramine (SNRI), fluoxetine (SSRI) and paroxetine (SSRI) all increased omissions at the highest dose tested. These data suggest that the SNRIs and SSRIs reduce premature responding but tend to be less specific than noradrenaline specific reuptake inhibitors in this model. SSRIs did not induce any specific impairment in impulse control in this model.

Sensation seeking as risk factor for suicidal ideation and suicide attempts in adolescence

BACKGROUND

High sensation seeking in adolescence is associated with engagement in risk-taking behaviors, especially substance use. Although depressed adolescents are prone to increased risk-taking, and suicidal behavior can be considered within the spectrum of risk-taking behaviors, the relationships between sensation seeking, depression, and suicidal behavior have not been explored.

METHODS

A self-report questionnaire assessing sensation seeking, depression, substance use problems, and suicidal ideation and suicide attempts was completed by 9th- through 12th-grade students (n=2189) in six New York State high-schools from 2002 through 2004. Logistic regression analyses were conducted to examine main and interaction effects between sensation seeking and the four clinical variables.

RESULTS

High sensation seeking was positively associated with depressive symptoms and substance use problems. The main effects of sensation seeking on suicidal ideation and suicide attempts remained significant after controlling for depression and substance use. The association between sensation seeking and suicide attempts was moderated by substance use problems.

LIMITATIONS

The schools were suburban and predominantly white, limiting the generalizability of the results. Other mental disorders with potential implications for sensation seeking and for suicidal behavior, such as bipolar disorders, were not assessed.

CONCLUSIONS

The finding that sensation seeking makes an independent contribution to the risk of suicidal ideation and attempts is consistent with findings in literature on novelty seeking and impulsivity. The associations between sensation seeking, depressive symptoms and suicidal behavior may be compatible with the presence of an underlying temperamental dysregulation. Screening for sensation seeking may contribute to the reduction of adolescent suicide risk.

Detecting Suicidality From Facial Appearance

Suicide is a pervasive problem worldwide. In this investigation, we show that individuals can perceive suicidality from facial appearance with accuracy that is significantly greater than chance guessing. Inferences of expected or obvious cues, such as how depressed a person seems, did not lead to accurate judgments. Rather, perceptions of how impulsive an individual appears differentiated suicide victims from living controls. Teasing apart various forms of impulsivity revealed that perceptions of impulsive aggression, distinct from other forms of impulsive behavior (e.g., impulsive buying), distinguished suicide victims from controls. Finally, experienced mental health clinicians did not perform significantly better than laypersons at judging suicidality. Facial appearance may therefore hold cues to suicidality, expanding what is known about the expression and perception of social cues from the face and providing new insights into the relationship between mental health and nonverbal cues.

Borderline personality disorder and depression: an update

To review the literature related to recent temperamental and biological findings on borderline personality disorder (BPD) and major depression, the close link between the two disorders, and the latest therapeutical findings on BPD, focusing on the conditions of co-morbidity between depression and BPD. The National Institutes of Health's PubMed database was used to identify indexed studies on BPD, depression and the co-morbidity between the two. Only studies published between 2000 and 2011 were assessed. Similar temperamental features have been demonstrated in BPD and depression. The strong link between the two disorders seems to be widely recognized by scientific community. Psychotherapy and new antipsychotics are the topics of current major interest of research. The therapeutic targets in the case of co-morbidity are BPD features associated with depressive symptoms, thus influencing prognosis. A global assessment is, in fact, fundamental for a successful therapy for the treatment of the several aspects of a complex psychopathological phenomenon.

Callous-unemotional traits as a cross-disorders construct

PURPOSE

Callous-unemotional (CU) traits are currently viewed as the defining signs and symptoms of juvenile psychopathy. It is unclear, however, whether CU traits have validity only in the context of conduct disorder (CD) as proposed by Frick and Moffitt (A proposal to the DSM-V childhood disorders and the ADHD and disruptive behavior disorders work groups to include a specifier to the diagnosis of conduct disorder based on the presence of callous-unemotional traits, American Psychiatric Association, Washington, DC, 2010), or also outside CD, either in combination with other forms of psychopathology or as a stand-alone construct.

METHODS

The current review systematically studied the existent literature on CU traits in juveniles to examine their validity inside and outside CD according to the framework regarding the validity of a psychiatric diagnosis provided by Robins and Guze (Am J Psychiatry 126:983-987, 1970).

RESULTS

Inside youth with conduct problems, and CD specifically, it seems that CU traits meet the Robins and Guze criteria. As many of the reviewed studies included youth with ODD and ADHD as well, there are indications the same might be true for ODD and ADHD, although probably to a lesser extent. In other disorders, CU traits may be present as well, but their role is not firmly established. As stand-alone construct, data are lacking or are scarce on all of the above-mentioned criteria.

CONCLUSIONS

CU traits are a useful specifier in CD, and possibly also in disruptive behaviour disorders (DBDs) more generally. High CU traits outside DBDs exist but it is as yet unknown if there is a clinical need for defining CU traits as a stand-alone construct.

Associations between relational aggression, depression, and suicidal ideation in a child psychiatric inpatient sample

The current study examined relations between relational aggression, depressive symptoms, and suicidal ideation in a child clinical population. Participants included 276 children (M(age) = 9.55 years; 69% Male) who were admitted to a child psychiatric inpatient facility. Findings suggested that relational aggression was associated with depressive symptoms, which in turn was associated with suicidal ideation. The test of indirect effects suggested that depressive symptoms fully accounted for the link between relational aggression and suicidal ideation. Moreover, these relations were found when also controlling for the variance associated with overt aggression, history of abuse, and social problems. Current findings appear to suggest that relational aggression is linked to depressive symptoms, which is linked to suicidal ideation within a clinical population, and as such there may be clinical utility in assessing relational aggression.

Suicide-related behaviors and anxiety in children and adolescents: a review

This paper reviews empirical evidence of the association between suicide-related behaviors and anxiety among children and adolescents. It begins with a review of suicide-related behaviors and anxiety, discusses methodological issues related to measurement, and reviews empirical findings published since the last review of this topic in 1988. Evidence is summarized on four criteria necessary to establish anxiety as a causal risk factor for suicide-related behaviors among children and adolescents. There is consistent evidence for a significant association between anxiety and suicide-related behaviors (Criterion 1). Evidence that the influence of anxiety on suicide-related behaviors is not due to a third variable (Criterion 2) is mixed and hindered by methodological limitations. The literature is also unclear as to whether anxiety temporally precedes suicide-related behaviors (Criterion 3). Finally, this review found no evidence to support or refute anxiety's stability independent of and across instances of suicide-related behaviors (Criterion 4). Theoretical and clinical implications of these findings and directions for future research are discussed.

Dimensions of adolescent psychopathology and relationships to suicide risk indicators

Youth suicide represents an area of important public and mental health concern. Although diagnostic correlates (e.g., depression) of suicidality have been identified, very few studies of youth have analyzed relationships between empirically-derived dimensions of psychopathology, representing broader dimensions of risk, and different suicidality indicators. We recruited 223 adolescents (57% female; 32% ethnic minority) from mental health agencies and the community to assess psychopathology, substance use, and suicidality relying on multiple measures and reporters (youth, parent, and clinician). Using a 3-factor model of psychopathology, we found that the Internalizing factor (including depression and generalized anxiety) was associated with both suicidal thinking and behaviors (threats/attempts), the Externalizing factor (conduct, oppositional, and attention deficit disorders) was negatively related only to suicidal thinking, and the Substance Use factor (alcohol and cannabis use) related to suicidal behaviors of threats/attempts but not suicidal thinking. The results show the utility of a dimensional conceptualization for clarifying distinct vulnerabilities to suicidal thinking versus overt behaviors and have implications for the construct validity of distinct dimensions of psychopathology.