A within-person approach to risk for suicidal ideation and suicidal behavior: Examining the roles of depression, stress, and abuse exposure

Negative life events and suicidality among adolescents in Western China: the mediating effect of depressive symptoms and the moderating effect of self-esteem

OBJECTIVE

To investigate the mediating role of depressive symptoms in the relationship between negative life events (NLEs) and suicidality, as well as to test the moderating effect of self-esteem in the mediation model.

METHODS

A total of 3,003 adolescents from Han, Tibetan, and Yi ethnic groups living in Western China were included in this study. Utilizing the structural equation model, a mediation model and a moderated mediation model were constructed.

RESULTS

The presence of NLEs was positively associated with suicidality (β = 0.17, p < 0.001). Depressive symptoms partially mediated the relationship between NLEs and suicidality (indirect effect β = 0.19, p < 0.001). Self-esteem moderated both the antecedent and subsequent segments of the mediating paths of "NLEs → depressive symptoms → suicidality" and the direct relationship between NLEs and suicidality. Among adolescents with a low level of self-esteem, the mediating effect coefficient of depressive symptoms was higher at 0.18 (95% confidence interval (CI): 0.14-0.23), in contrast to adolescents with a high level of self-esteem, where the mediating effect coefficient of depressive symptoms was 0.04 (95% CI: 0.02-0.07).

CONCLUSION

NLEs are directly associated with an increased risk of suicidality and indirectly related to suicidality by increasing the risk of depressive symptoms among adolescents. Self-esteem can moderate the mediating effect of depressive symptoms and the relationship between NLEs and suicidality. The intervention strategy for preventing suicidality among adolescents who have experienced NLEs should focus on reducing depressive symptoms and improving self-esteem.

A longitudinal study of adolescent pathways differentiating suicide ideation and attempt in early adulthood

OBJECTIVE

Suicide ideation and attempt are leading risk factors for mortality in young adults. However, the adolescent risk factors distinguishing suicide ideation from attempt in young adults remain unclear. The present study aimed to examine the extent to which within-person stability and change in depressive symptoms, school difficulties, and peer victimization from ages 12 to 17 were differentially associated with later suicide ideation and attempt from ages 20 to 23.

METHOD

The study included 1647 participants from the Quebec Longitudinal Study of Child Development (QLSCD; 52% female). Participants reported on their depressive symptoms, school difficulties, and peer victimization at ages 12, 13, 15, and 17, and on suicide ideation and attempt at ages 20 and 23. Data were collected in the Province of Quebec, Canada, between 2010 and 2021.

RESULTS

Results indicated that 11% (N = 121) and 8% (N = 86) reported suicide ideation and attempt, respectively, between ages 20 and 23. A random-intercept cross-lagged panel model showed that within-person increases in depressive symptoms during adolescence were related to both suicide ideation and attempt, whereas within-person increases in school difficulties and peer victimization were for the most part related to suicide attempt only. Within-person stability in depressive symptoms from ages 12 to 17 years were also related to suicide attempt, and not ideation. However, this association was only marginally significant.

CONCLUSION

Findings suggest that experiencing unusual rises in school difficulties and peer victimization during adolescence, as well as depressive symptoms persisting over time, may distinguish young adults who think about suicide from those who attempt suicide.

Network structure of adolescent social, emotional, and behavioral difficulties and their differential relationships with suicidality

BACKGROUND

Social, emotional, and behavioral difficulties (SEBDs) tend to develop during adolescence. Their presence and especially co-occurrence induce numerous disrupting consequences, including suicidality. A recently developed network analysis is suitable to investigate the symptom-level structure of comorbid psychopathology. Rather than pairwise comorbidity networks, the current study investigated a comprehensive network of SEBDs at the symptom level and explored the differential relationships between symptoms of SEBDs and suicidality.

METHODS

Recruited from four public schools in China, a sample of adolescents (N = 6974, mean age = 15.84, 50.1% boys) were assessed with the Strengths and Difficulties Questionnaire (SDQ) and one suicidality-related item. The cross-sectional network structure of the SEBD symptoms was investigated. The differential associations between individual symptoms of SEBDs and suicidality were also explored with a relative importance analysis.

RESULTS

The results showed that constantly fidgeting, worry a lot, unhappy, down-hearted, tearful, and easily scared emerged as the most central symptoms in the network of SEBDs. Worry a lot, constantly fidgeting, lose my temper, and being bullied served as bridge symptoms, connecting various domains of SEBDs. In addition, the centrality of symptoms was positively associated with the variance shared with suicidality, with worry a lot and unhappy, down-hearted, and tearful explaining a large portion of the variance of suicidality.

CONCLUSIONS

Taken together, the results were indicative of close connections among emotional, hyperactivity-inattention, peer, and conduct aspects of adolescent mental health difficulties, as well as the central role of emotional difficulties in the SEBDs network.

Neural Markers of Emotion Reactivity and Regulation Before and After a Targeted Social Rejection: Differences Among Girls With and Without Suicidal Ideation and Behavior Histories

BACKGROUND

Suicidal thoughts and behaviors (STBs) are common among adolescent girls and increase risk for suicide death. Emotion regulation difficulties are linked with STBs, particularly in response to targeted social rejection. However, neural correlates of this link have not been investigated and may identify novel targets for interventions. Here, we examined neural correlates of emotion regulation before and after an experimentally delivered targeted social rejection in adolescent girls with STBs and girls without STBs (i.e., control participants).

METHODS

Girls (N = 138; age range, 9-15 years; mean [SD] age = 11.6 [1.79] years) completed a functional neuroimaging emotion regulation task. In the middle of the task, participants were socially rejected by an unfamiliar confederate whom the participants had elected to meet. Participants also completed a multimethod STB assessment.

RESULTS

Before rejection, girls with a history of STBs, compared with control participants, showed greater activation in the right superior frontal gyrus when passively viewing negative stimuli, and girls with suicidal behavior (SB) versus those without SB showed less activation in the right frontal pole during emotion regulation attempts. Following the rejection, girls with STBs, compared with control participants, showed greater activation in the right inferior frontal gyrus during emotion regulation.

CONCLUSIONS

Before social rejection, girls with SB versus without SB may not activate brain regions implicated in emotion regulation, suggesting a vulnerability to poor regulation at their baseline emotional state. After social rejection, girls with any history of STBs showed altered activation in a brain region strongly associated with inhibition and emotion regulation success, possibly reflecting increased effort at inhibiting emotional responses during regulation following stress exposure.

Personal and work-related burnout is associated with increased episodes of suicidal ideation or behavior among working adults in Chile

Burnout has been previously associated with suicidal risk factors and suicide itself, but these associations have only focused on work-related burnout among high-demand occupations. We aimed at examining the extent to which personal and/or work-related burnout are associated with suicidal ideation or behavior among working adults in Chile. We conducted a cross-sectional study among 1,970 working adults attending the Hospital del Trabajador in Santiago, Chile, between September 2015 and February 2018, using structured interviews. The Copenhagen Burnout Inventory (CBI) assessed levels of personal and work-related burnout (mild, moderate, and high-to-severe), and the Columbia Suicidal Rating Scale (C-SSRS) measured suicidal ideation or behavior. Multivariable logistic regression models were fit to estimate the magnitude of the association between burnout with suicidal ideation or behavior. After adjusting for putative confounders, moderate and high-to-severe personal burnout were associated with 5.07-fold (95% confidence interval (Al-Halabí et al.): 3.56-7.26) and 10.26-fold (95% CI: 5.75-18.50) increased odds of suicidal ideation or behavior, and high-to-severe work-related burnout associated with 2.47-fold increased odds (95% CI: 1.31-4.68). The dose-response pattern was shown in the association between both types of burnout and suicidal ideation or behavior (p for trend <0.05). Personal and work-related burnout were associated with increased odds of suicidal ideation or behavior in a dose-response manner. Focusing on alleviating burnout levels through mental health services or social support may effectively decrease the prevalence of suicidal ideation or behavior among working adults.

Predicting Acute Changes in Suicidal Ideation and Planning: A Longitudinal Study of Symptom Mediators and the Role of the Menstrual Cycle in Female Psychiatric Outpatients With Suicidality

OBJECTIVE

Cross-sectional and preliminary longitudinal findings suggest that cyclical ovarian hormone fluctuations influence acute suicide risk. The authors provide the first analyses in females with suicidality to investigate which daily symptoms covary with suicidal ideation and planning thoughts, the role of the menstrual cycle in daily symptom variation, how daily fluctuations in symptoms mediate the menstrual cycle-suicidality relationship, and how these associations vary across individuals.

METHODS

Naturally cycling psychiatric outpatients (N=119) with past-month suicidal ideation provided daily ratings of psychiatric symptoms (depression, hopelessness, anxiety, feeling overwhelmed, agitation, anhedonia, worthlessness, rejection sensitivity, anger, perceived burdensomeness, and interpersonal conflict), suicidal ideation, and suicidal planning across at least one menstrual cycle. Symptom ratings were decomposed into trait (person-centered mean) and state (daily person-centered mean deviation) components. Five cycle phases were identified in relation to menses onset and ovulation (surge in urine luteinizing hormone level). Hypotheses were tested in multilevel structural equation models.

RESULTS

Nearly all psychiatric symptoms covaried with fluctuations in daily suicidal ideation, and a limited set of symptoms (depression, hopelessness, rejection sensitivity, and perceived burdensomeness) predicted within-person increases in suicidal planning. Many patients demonstrated perimenstrual worsening of psychiatric symptoms, suicidal ideation, and suicidal planning. Depressive symptoms (depression, hopelessness, perceived burdensomeness, and anhedonia) were the most robust statistical mediators predicting perimenstrual exacerbation of suicidality.

CONCLUSIONS

Research on the menstrual cycle and suicide has been limited historically by small, cross-sectional samples. This study provides the first evidence that measuring day-to-day correlates of suicidality in a large transdiagnostic sample of females with suicidal ideation can contribute to understanding the pathways by which the menstrual cycle influences acute suicide risk.

The temporal relationship between marriage and risk for suicidal ideation

BACKGROUND

Marriage is consistently identified as a protective factor for suicidality, but it remains unclear whether this relationship varies by time elapsed since the transition to marriage.

METHODS

Participants were 15,870 individuals (52 % female, mean age = 44.63 years, age range = 18-99 years) from the Collaborative Psychiatric Epidemiology Surveys. Cox proportional hazards models were used to test the relationship between marriage, as well as time elapsed since the transition to marriage (0-5 years, 6-10 years, or 11+ years), and suicidal ideation. Years of education and race and ethnicity were included as covariates, and analyses were stratified by sex. Separate hazard ratios were estimated for individuals aged <30 years and 30+ years to address violations of the proportionality assumption.

RESULTS

Being married was associated with lower risk for suicidal ideation across age and sex. Among individuals aged <30 years, marriage was reliably associated with lower risk for suicidal ideation, regardless of the time elapsed since marriage. For individuals aged 30+ years, being married for 0-5 years or 6-10 years was associated with increased risk for suicidal ideation, particularly in females. Being married for 11+ years was associated with decreased risk across sex.

LIMITATIONS

Analyses focused on participants' first marriage and did not examine mediators of the association between marriage and suicidal ideation.

CONCLUSIONS

Overall, being married protects against suicidal ideation. However, among individuals aged 30 years or older, the first 10 years of marriage are associated with elevated risk for suicidal thoughts, and clinical outreach may be warranted.

Mood Disorders and Aggressive Traits Mediate Effects of Reported Childhood Adversity on Suicide Attempt Risk

BACKGROUND

Childhood adversity (CA) is linked to suicidal behavior as well as to mood disorders and aggressive traits. This raises the possibility that depression and aggressive traits mediate the relationship of childhood adversity to suicide risk. Moreover, it is not known if they operate independently or interactively.

AIMS

To determine whether, and how, mood disorders and aggressive traits mediate the effects of reported physical and sexual abuse on future suicidal behavior.

METHODS

Five hundred and forty-eight subjects, offspring of parents with mood disorders, were interviewed at baseline and at yearly follow-ups with questionnaires assessing aggression, mood disorders, and suicidal behavior. The mediation analysis involved a three-step process, testing the relationships between (1) CA and attempt; (2) CA and putative mediators; and (3) putative mediators and suicide attempt, adjusting for CA.

RESULTS

Aggressive trait severity and mood disorder onset each mediated the relationship between CA and future suicide attempts. Greater aggression severity also raised the hazard of the development of a mood disorder. If aggressive trait severity was clearly elevated, then onset of mood disorder did not increase further the hazard of the suicide attempt. Including family as a random effect had a much bigger effect on attempt outcome for physical abuse compared with sexual abuse.

CONCLUSIONS

Amelioration of aggressive traits and treatment of mood disorders in CA-exposed offspring of a parent with a mood disorder may prevent future suicide attempts and may reduce the risk of mood disorder. Familial factors influence the impact of childhood physical abuse but not sexual abuse. HIGHLIGHTSChildhood Adversity (CA) predicted future mood disorder and aggression severity.Depression and aggression mediate the relationship between CA and suicide attempts.When one mediator is present, the presence of the other does not increase the hazard.Between family variation contributed much more to suicidal behavior outcomes relative to the effect of physical abuse, but sexual abuse contributed to suicidal outcomes more than family variation.

Interpersonal stress and proinflammatory activity in emerging adults with a history of suicide risk: A pilot study

Interpersonal stress during adolescence and young adulthood can threaten healthy developmental trajectories. A "primed" proinflammatory response to acute stress may serve as an underlying process that results in negative outcomes for youth. The present pilot study examined the relation between interpersonal stress and two proinflammatory cytokines in a sample of 42 university-recruited emerging adults with recent suicidal thoughts and behaviors. Participants completed self-report measures of mood, suicidal thoughts and behaviors, recent peer-related stressors, and interpersonal sensitivity. They also participated in an acute laboratory social stress task and provided three saliva samples to measure their proinflammatory responses (IL-6 and TNF-α) to the stressor. Participants reported significant increases in sadness and exclusion, and significant decreases in inclusion, following task participation. Importantly, no participants reported an increase in or onset of suicidal thoughts. No significant associations between interpersonal stress and proinflammatory cytokines were found. Changes in affect during the task coupled with lack of increased suicidal thoughts indicate it is acceptable to use this exclusion and rejection paradigm with this population, with proper debriefing and positive mood induction procedures. Given all other nonsignificant associations, future research considerations are discussed, including impact of COVID-19 on task potency and incorporation of multiple stress response systems.

Childhood trauma and internalizing and externalizing behavior problems among adolescents: Role of executive function and life events stress

INTRODUCTION

Exposure to childhood trauma is found to increase internalizing and externalizing behavior problems in adolescents, however, the potential mechanism of this link remains underexplored. This study investigated the associations between childhood trauma and internalizing and externalizing behavior problems among adolescents, and tested the mediating role of executive function and the moderating role of life events stress in this relationship.

METHODS

Questionnaire data were collected from 952 junior students in Northwest China. Participants ranged in age from 11 to 15 years old (M = 12.88 years, SD = 0.72; 53% females). SPSS 26.0 was used to analyze the relationship between variables and examine the mediation model and the moderated mediation model.

RESULTS

Childhood trauma was positively associated with internalizing and externalizing behavior problems among adolescents. In addition, executive function partially mediated the relations between childhood trauma and internalizing and externalizing behavior problems. Life events stress was observed to moderate the relations between childhood trauma and executive function, as well as executive function and internalizing and externalizing behavior problems, but the effect sizes were relatively small.

CONCLUSIONS

These findings underscore the role of executive function and life events stress in the association between childhood trauma and behavioral problems among adolescents.

Associations Between Family Factors, Social Integration, and Suicidal Ideation Across the Life Course of an Urban African American Cohort

Suicide is a problem on the rise but not studied extensively among African Americans. It is critical to identify risk factors for suicidal ideation to reduce risk. This study examines whether family and social factors over the life course predict suicidal ideation among African American adults in midlife. We conducted multiple logistic regression analyses on data from a longitudinal cohort of African Americans first assessed in childhood to identify associations with suicidal ideation in midlife (ages 33-42). Findings suggested living without one's mother in childhood (vs. living with mother alone; aOR = 3.69, p = .017) and parental rule-setting in adolescence (aOR = 0.79, p = .047) were associated with suicidal ideation. Having a lifetime drug disorder (aOR = 2.19, p = .046) or major depression by young adulthood (aOR = 3.58, p < .001) was also associated with an increased risk of suicidal ideation. Findings highlight the importance of intervention for children in mother-absent homes for improving mental health outcomes. Family interventions that promote parental rule-setting and addressing drug problems and depressive symptoms early in the life course offer an area for intervention to reduce suicide over the long term.

The role of stress phenotypes in understanding childhood adversity as a transdiagnostic risk factor for psychopathology

Childhood adversity is a leading transdiagnostic risk factor for psychopathology, being associated with an estimated 31-62% of childhood-onset disorders and 23-42% of adult-onset disorders (Kessler et al., 2010). Major unresolved theoretical challenges stem from the nonspecific and probabilistic nature of the links between childhood adversity and psychopathology. The links are nonspecific because childhood adversity increases risk, through a range of mechanisms, for diverse forms of psychopathology and are probabilistic because not all individuals exposed to childhood adversity develop psychopathology. In this article, we propose a path forward by focusing on stress phenotypes, defined as biobehavioral patterns activated in response to stressors that can disrupt future functioning when persistent (e.g., reward seeking, social withdrawal, aggression). This review centers on the accumulating evidence that psychopathology appears to be more strongly predicted by behavior and biology during states of stress. Building on this observation, our theoretical framework proposes that we can model pathways from childhood adversity to psychopathology with greater specificity and certainty by understanding stress phenotypes, defined as patterns of behavior and their corresponding biological substrates that are elicited by stressors. This approach aims to advance our conceptualization of mediating pathways from childhood adversity to psychopathology. Understanding stress phenotypes will bring us closer to "precision mental health," a person-centered approach to identifying, preventing, and treating psychopathology. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

An RDoC-based approach to adolescent self-injurious thoughts and behaviors: The interactive role of social affiliation and cardiac arousal

Recent theoretical models have posited that increases in self-injurious thoughts and behaviors (SITBs) during adolescence may be linked to failures in biological stress regulation in contexts of social stress. However, there is a lack of data examining this hypothesis during the transition to adolescence, a sensitive period of development characterized by changes across socioaffective and psychophysiological domains. Building on principles from developmental psychopathology and the RDoC framework, the present study used a longitudinal design in a sample of 147 adolescents to test whether interactions among experiences of social (i.e., parent and peer) conflict and cardiac arousal (i.e., resting heart rate) predicted adolescents' engagement in SITBs (i.e., nonsuicidal self-injury, NSSI; and suicidal ideation; SI) across 1-year follow-up. Prospective analyses revealed that adolescents experiencing a combination of greater peer, but not family, conflict and higher cardiac arousal at baseline showed significant longitudinal increases in NSSI. In contrast, social conflict did not interact with cardiac arousal to predict future SI. Findings indicate that greater peer-related interpersonal stress in adolescents may increase risk for future NSSI among youth with physiological vulnerabilities (i.e., higher resting heart rate) that may be markers of maladaptive stress responses. Future research should examine these processes at finer timescales to elucidate whether these factors are proximal predictors of within-day SITBs.

A Latent Class Analysis of Suicidal Behaviors in Adolescents

OBJECTIVE

The purpose of the present study was to identify adolescents' suicide subgroups using five indicators (depression, anxiety, suicide ideation, and planned and attempted suicide), and explore the distinctive features of each subgroup.

METHODS

This study included 2,258 teenagers from four schools. Both adolescents and their parents, who voluntarily agreed to participate in the study, completed a series of self-reported questionnaires on depression, anxiety, suicide, self-harm, self-esteem, impulsivity, childhood maltreatment, and deviant behaviors. The data were analyzed using latent class analysis, a person-centered method.

RESULTS

Four classes were detected: "high risk for suicide without distress," "high risk for suicide with distress," "low risk for suicide with distress," and "healthy." The "high risk for suicide with distress" class was the most severe on all evaluated psychosocial risk factors, namely, impulsivity, low self-esteem, self-harming behaviours, deviant behaviour problems, and childhood maltreatment, followed by "high risk for suicide without distress."

CONCLUSION

This study identified two high risk subgroups for adolescent' suicidality, "high risk for suicide with or without distress." Both high risk subgroups for suicide showed higher scores for all psychosocial risk factors than low risk subgroups for suicide. Our findings suggest that special attention needs to be paid to the latent class "high risk for suicide without distress," as this group's "cry for help" might be relatively difficult to detect. Specific interventions for each group (e.g., distress safety plans for "suicidal potential with or without emotional distress") need to be developed and implemented.

Association between Suicidal Behaviors in Adolescence and Negative Emotions, the Level of Stress, Stress Coping Strategies and the Quality of Sleep

Suicidal behaviors in adolescents stem from complex processes deeply rooted in various spheres of life and functioning. The study was aimed at assessing the relationship between selected negative emotions, the quality of sleep, the level of perceived stress as well as stress coping strategies and suicidal ideation and attempts among high school students. The examined group consisted of adolescents aged 16-18 recruited by social-media groups in Poland. The study was based on a diagnostic survey with the application of CAWI method. The other research tools applied in the study included: Hospital Anxiety and Depression Scale-Modified, Perceived Stress Scale-10, How do you cope?-Questionnaire, Athens Insomnia Scale as well as the authors' own questionnaire on suicidal ideation and suicide attempts. Anxiety, depression, aggression and insomnia as well as a high level of stress were statistically more common in girls than in boys (p < 0.001). The high level of negative emotions and insomnia, in turn, increased the risk of suicidal ideation (OR = 3.59, 95% CI: 2.13-6.06 and OR = 2.35, 95% CI: 1.60-3.46), as well as suicide attempts (OR = 6.29, 95% CI: 2.93-14.80 and OR = 3.29, 95% CI: 2.07-5.35). Additionally, high level of stress was associated with more than twice larger odds of suicidal ideation (OR = 2.26, 95% CI: 1.13-4.63). Significantly higher prevalence of suicidal ideation (p = 0.017) and suicide attempts (p = 0.016) was observed in girls. A high level of negative emotions and stress accompanied by a low quality of sleep are factors predisposing people to suicidal ideation and attempted suicide.

Assessing sleep health dimensions in frontline registered nurses during the COVID-19 pandemic: implications for psychological health and wellbeing

The COVID-19 pandemic altered work environments of nurses, yielding high rates of stress and burnout. Potential protective factors, including effective sleep, may influence psychological health and wellbeing. Evidence about sleep in nurses may help develop interventions that mitigate burnout and poor psychological outcomes. A cross sectional survey was distributed across three hospitals to nurses in New York City (NYC). During the first wave of the pandemic (March-April 2020), NYC had the highest incidence of laboratory-confirmed COVID-19 cases (915/100 000) and half of all COVID-related deaths nationwide. Multivariable logistic regression was used to determine associations between Pittsburgh Sleep Quality Index (PSQI) global sleep score, PSQI sleep dimensions, and psychological health (burnout, depression, anxiety, and compassion fatigue), unadjusted and then controlling for individual and professional characteristics. More than half of the participants reported burnout (64%), depression, (67%), and anxiety (77%). Eighty percent of participants had PSQI global scores >5 (poor sleep) (mean 9.27, SD 4.14). Respondents reporting good sleep (PSQI ≤ 5) had over five times the odds of no burnout (OR: 5.65, 95% CI: 2.60, 12.27); increased odds of screening negative for depression (OR: 6.91, 95% CI: 3.24, 14.72), anxiety (OR: 10.75, 95% CI: 4.22, 27.42), and compassion fatigue (OR: 7.88, 95% CI: 1.97, 31.51). Poor subjective sleep quality PSQI subcomponent was associated with burnout (OR: 2.21, 95% CI: 1.41, 3.48) but sleep duration subcomponent was not (OR: 0.84, 95% CI: 0.59, 1.19). Daytime dysfunction was significantly associated with all psychological outcomes. Sleep disturbances and medications yielded higher anxiety odds. Overall, sleep quality appears more strongly related to burnout than sleep duration in nurses working during the COVID-19 pandemic. Sleep interventions should target individual sleep dimensions in nurses.

A Pre-Adolescent and Adolescent Clinical Sample Study about Suicidal Ideation, Suicide Attempt, and Self-Harming

Suicide is the second cause of death among adolescents, and nonsuicidal self-injury (NSSI) is one of the main risk factors for suicidal behavior. However, the possible variables specifically associated with suicidal ideation and suicide attempt, as well as the psychopathological characteristics linked to the concomitant presence of suicidal ideation/attempt and NSSI are still under-investigated in youth. The current study aimed to address these issues in a sample of 174 young Italian inpatients (M_age = 14.3 years ± 1.93, 78.2% girls). Sociodemographic and clinical variables were assessed through psycho-diagnostic interviews and ad hoc questionnaires. A binomial logistic regression was performed to identify the predictors of suicidal ideation and suicide attempt. Then, Kruskal-Wallis tests were run to analyze the psychopathological differences between patients with suicidal ideation and suicide attempt considering the coexistence of NSSI. The results highlighted that previous access to child mental health services and general psychopathological problems significantly predicted suicidal ideation, while previous hospitalizations, borderline personality functioning, and affective disorders significantly predicted suicide attempt. In general, inpatients with also NSSI reported higher levels of internalizing, somatic and total problems, impulsiveness, alexithymia, and emotional dysregulation. The clinical implications of our findings in terms of primary and secondary preventive programs are discussed.

Child Sexual Abuse and Suicide: Essentials for the Forensic Nurse

Sexual abuse can result in significant negative sequelae for victims. One particularly harmful consequence is suicidal ideation, which can lead to suicide attempts and even death. It is essential to screen children and adolescents for suicidal ideation when providing medical forensic care after disclosure of acute or nonacute sexual abuse/assault. Forensic nurses must feel confident in their abilities to assess suicide risk and provide appropriate intervention and referrals. A thorough understanding of the relationship between sexual abuse and suicidal ideation and behaviors can assist the forensic nurse in the development of practice behaviors to better identify, intervene, and prevent suicidal ideation and behaviors among youth experiencing sexual abuse.

Prevalence of lifetime self-injurious thoughts and behaviors in a global sample of 599 patients reporting prospectively confirmed diagnosis with premenstrual dysphoric disorder

BACKGROUND

Suicide is the second leading cause of death among Americans ages 10 to 34, with alarming recent increases in suicide rates among those assigned female at birth. A large body of evidence points to menstrual cycle influences on self-injurious thoughts and behaviors (STBs), suggesting that neurobiological hormone sensitivities, such as in premenstrual dysphoric disorder (PMDD), may drive suicide risk in females. However, existing studies of STBs in PMDD use cross-sectional self-report measures of PMDD with poor validity. As a first step to establish accurate prevalence rates of STBs in PMDD, we examined the lifetime prevalence of STBs in a large global survey of patients reporting a diagnosis of PMDD based on daily ratings.

METHOD

Individuals with self-reported PMDD symptoms were invited to an online survey through online support groups for PMDD and social media posts from PMDD awareness accounts. Participants reported demographics, whether they had been diagnosed with PMDD by a healthcare provider using daily ratings, STBs using the Columbia Suicide Severity Rating Scale, and history of lifetime comorbid psychiatric diagnoses.

RESULTS

Of 2,689 survey completers, 599 (23%) reported a diagnosis with PMDD based on two months of daily ratings and were included in analyses. We observed high rates of lifetime active suicidal ideation (72%), planning (49%), intent (42%), preparing for an attempt (40%), and attempt (34%), as well as non-suicidal self-injury (51%). The majority (70%) of the sample reported at least one lifetime comorbid psychiatric diagnosis. Predictors of lifetime active suicidal ideation included nulliparity, low-to-moderate (vs. high) income, and history of diagnosis with major depression or post-traumatic stress disorder. Predictors of lifetime attempts among those reporting lifetime active ideation included older age, nulliparity, lower income, and history of diagnosis with post-traumatic stress disorder or borderline personality disorder.

CONCLUSIONS

These data indicate high rates of STBs among those reporting prospective diagnosis of PMDD and highlight the need for prospective research on mechanisms and prevention of STBs in PMDD. Clinical practice guidelines for PMDD should accommodate comorbidities and recommend frequent screenings for STB risk. STBs should be considered for inclusion in future iterations of the DSM PMDD diagnostic criteria.

Sociodemographic and clinical characteristics of paediatric patients admitted to a neuropsychiatric care hospital in the COVID-19 era

Background

Since the first months of 2020, Italy and the world have been facing the COVID-19 pandemic. In addition to the dangerous and potentially deadly effects on physical health, it has caused a radical change in the lifestyle of the population and a potential danger for mental health too. These events were inserted into the context of a growing epidemiological trend regarding children’s psychiatric disorders in the past decade.

Aim

To study the population of patients admitted to a Neuropsychiatric Hospital Unit of North Italy in the first COVID-19 year, comparing them with the population of patients hospitalised during the year immediately before, according to sociodemographic and clinical variables.

Methodology

The study is an observational retrospective cohort. In total, 198 patients hospitalised due to neuropsychiatric problems from February 2019 to March 2021 were recruited. Data were analysed through mean and standard deviation, t-test, percentages, chi square test, and the Fischer exact test.

Results

Risk factors associated with mental health disorders were similar between the two years. The hospitalisation modality showed a decrease in scheduled hospitalisations compared to urgent ones, and among the reasons that led patients to hospitalisation there was a conspicuous increase in eating disorders. More suicidal and self-harming behaviours occurred in the COVID-19 group too, compared to the previous year. The methods used to attempt suicide were changed considerably, with a prevalence of that attempted within the home. Changes in pharmacological therapies also occurred, necessary for more than 80% of inpatients during the COVID year, with a greater use of neuroleptics. There were alarming data about hospitalisation relapses, which increased from 12.2% in the pre-COVID year to 35.0% in the COVID year.

Conclusion

Data shed light on clinical and policy issues in mental health care during the developmental age. Since the COVID-19 health emergency is not yet over, and its effects, especially on mental health, will be long-term, it is necessary to implement services and activities dedicated to both primary and secondary prevention of neuropsychiatric diseases especially during adolescent ages.

COVID-19-Specific Suicidal Thoughts and Behaviors in Psychiatrically Hospitalized Adolescents

This study examined the presence and correlates of COVID-specific suicidal thoughts and behaviors (i.e., thoughts of or engaging in intentional COVID-19 exposure with associated suicidal intent) among psychiatrically hospitalized adolescents. Adolescents (N = 143) completed study measures as part of the standard intake process between March 13th and August 14th, 2020. Participants answered questionnaires assessing COVID-specific passive and active suicidal ideation (SI) and suicidal behavior, as well as COVID-related stressors and emotions, and public health guidance compliance. Findings highlights that COVID-specific SI is common in high-risk youth. COVID-specific SI was associated with COVID-19-related negative emotions, elevated stress, and decreased public health guidance compliance. Results suggest that COVID-specific suicidal thoughts and behaviors, and risk correlates, should be assessed within high-risk populations to facilitate prevention of risky behavior associated with intentional COVID-19 exposure.

Association of the type of counselor with suicidal ideation and suicide attempts: a survey of South Korean adolescents

BACKGROUND

Counseling for adolescents who consider or attempt suicide may help reduce suicide rates. However, the impact of the type of counselor (e.g., father, mother, sibling, friend, teacher, other) on suicidal ideation/suicide attempts remains unclear. Therefore, we examined this association in Korean adolescents.

METHODS

Using data from the 2015 Korea Youth Risk Behavior Web-based Survey of 65,485 adolescents, we examined risk factors for suicidal ideation/suicide attempts according to sex using a multiple logistic regression analysis. In a subgroup analysis, we investigated the associations between counselor type and suicidal ideation/suicide attempts stratified by the cause of stress for both sexes.

RESULTS

Male participants were less likely to consider suicide when counseled by their mother (odds ratio [OR] 0.80; 95% confidence interval [CI] 0.70-0.90) or friend (OR 0.89; 95% CI 0.80-0.99) and to attempt suicide when counseled by a friend (OR 0.74; 95% CI 0.60-0.92) than were those who did not receive any counseling. Female participants were less likely to attempt suicide when counseled by their mother (OR 0.66; 95% CI 0.53-0.82) or friends (OR 0.70; 95% CI 0.58-0.83) than when not counseled. Furthermore, adolescents with achievement/career choice-related and family problems were at a lower risk of suicide ideation/suicide attempts when counseled by their mother or friend than when they received no counseling.

CONCLUSIONS

Suicidal ideation/suicide attempts showed different associations for both sexes in accordance with the type of counselor. Even if counseling by specialists for issues such as achievement/career choice-related or family matters is needed, the risk of suicide could be reduced through counseling by the people around them. Therefore, adolescents should form mutually supportive relationships through active communication with surrounding people.

Das Verstärkermodell der Suizidalität: Chronische Suizidalität bei der Borderline-Persönlichkeitsstörung verstehen und behandeln

Trotz großer Fortschritte in der evidenzbasierten Psychotherapie wird unser Versorgungssystem durch chronisch suizidale Patienten mit einer Borderline-Persönlichkeitsstörung (BPS) weiterhin stark herausgefordert. Die BPS ist mit einem hohen Suizidrisiko von 5–10% sowie einem hohen Selbstverletzungsrisiko von bis zu 80% behaftet. Therapeuten wie Angehörige fühlen sich oft überfordert und hilflos, wenn sie mit der Suizidalität der Patienten konfrontiert sind. Immer wieder kommt es so zu Therapieabbrüchen, Vorstellungen in Notaufnahmen oder akut-psychiatrischen Einweisungen. Bei der nichtsuizidalen Selbstverletzung (NSSV) – einem Verhaltensmuster, das gehäuft zusammen mit chronischer Suizidalität bei BPS auftritt – tragen Verstärkermechanismen (z.B. Nachlassen von Anspannung) dazu bei, dass sich Borderline-Patienten trotz längerfristig unangenehmen Folgen immer wieder selbst verletzen. Die Motive für NSSV und suizidales Verhalten können sehr unterschiedlich sein. Es spricht jedoch einiges dafür, dass die zugrunde liegenden Mechanismen ähnlich sind und sich hieraus wichtige therapeutische Interventionsmöglichkeiten ableiten lassen. In dieser Übersichtsarbeit werden die Hintergründe und Unterschiede von NSSV, Suizidideationen sowie Suizidversuchen bei chronisch suizidalen Borderline-Patienten dargestellt. Neuere Erkenntnisse der modernen Neuro- und Verhaltenswissenschaft werden in ein Verstärkermodell der Suizidalität integriert, von dem verhaltenstherapeutische Interventionen abgeleitet werden, die Therapeuten in ihrer Arbeit mit chronisch suizidalen Patienten unterstützen können.

Association of health-risk behaviors and depressive symptoms and anxiety symptoms: a school-based sample of Chinese adolescents

Background Depressive symptoms and anxiety symptoms of adolescents not only affect youth but also have wide-ranging impacts on the health of adults. The study was carried out to determine the epidemiological characteristics of depressive symptoms and anxiety symptoms and the associations between the two and health-risk behaviors in Chinese adolescents. Methods Participants were recruited from the junior and senior high schools in China. Data were collected by self-designed questionnaires. The questionnaires included questions about demographic characteristics, depressive symptom scales, anxiety symptom scales and nine categories of health-risk behaviors. Descriptive analysis and binary logistic regression were performed by SPSS 21.0 software. Results There were 4.4% of the participants with depressive symptoms. Approximately 32.0% of the participants had anxiety symptoms. Girls and general senior school students were risk factors for depressive symptoms and anxiety symptoms. Multiple health-risk behaviors were associated with depressive symptoms and anxiety symptoms in Chinese adolescents. Conclusion Depressive symptoms and anxiety symptoms were prevalent in Chinese adolescents. Their distribution was affected by certain health-risk behaviors. Multiple health-risk behaviors were associated with depressive symptoms and anxiety symptoms in Chinese adolescents.

The relationship between conventional clinical assessments and momentary assessments of symptoms and functioning in schizophrenia spectrum disorders: A systematic review

BACKGROUND

Symptoms and functioning are critical dimensions in those with schizophrenia and are typically measured using validated conventional clinical assessments. Researchers and clinicians have begun to use real-time digital methods, such as ecological momentary assessment (EMA), to assess symptoms and functioning in the moment and outside of traditional hospital and laboratory settings, which may yield more naturalistic data. Although digital methods have advantages, it is unclear whether these momentary assessments capture core aspects of symptoms and functioning.

OBJECTIVE

This systematic literature review aimed to evaluate the association between conventional clinical and momentary-based assessments of functioning and symptoms in individuals with schizophrenia.

METHODS

Studies were included if they met the following criteria: (1) written or translated into English; (2) peer-reviewed; (3) included primary quantitative data; (4) 60% of the clinical sample included persons with schizophrenia spectrum disorders; (5) included a clinical assessment of functioning and/or symptoms; (6) included active momentary assessment and/or passive data; and (7) assessed the relationship between the momentary and conventional clinical assessments.

RESULTS

A total of 49 studies (87 analyses) were included. Conventional clinical assessments of functioning and positive, negative, and depressive symptoms were related to momentary assessments of these symptom domains. Passive data was beneficial for assessing negative symptoms, but research is warranted for other domains.

CONCLUSIONS

The reviewed studies highlight the utility of EMA methodologies to collect detailed data on symptoms and functioning. Such data is being used to develop more sophisticated models of schizophrenia to enhance our understanding of important mechanisms and develop targeted interventions.

Factors affecting suicidal ideation among premenopausal and postmenopausal women

WHAT IS KNOWN ON THE SUBJECT?: Pre- and postmenopausal women (PPW) experience changes in physical, psychological and social health. South-East Asia's female suicide rate is the highest compared with other countries, and the suicide rate of PPW in these countries continues to increase. The most influential factor in Asian women's suicidal ideation is family conflict; specifically, if PPW in South Korea cannot express their anger, it results in a culture-bound syndrome called "Hwa-Byung." However, there is a lack of research on Asian PPW. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study found differences in individual- and community-level factors affecting suicidal ideation between pre- and postmenopausal women. Individual factors that commonly affected suicidal ideation were experiencing violence, stress and depression. Individual factors that affected the suicidal ideation of premenopausal women more than postmenopausal women were religious beliefs, alcohol use and chronic disease. Community level factors affecting suicidal ideation were locational depression and locational counselling for stress in premenopausal women and locational counselling for depression in postmenopausal women. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses could help prevent suicide by developing and applying community-based programmes for PPW, considering the specific socio-economic and cultural context and characteristics of Asian women. Mental health nurses could help PPW participate in programmes by preparing various interventions such as case management, personal counselling, physical activity, home-based mental health services, cognitive behavioural therapy and digital interventions for self-management. Mental health nurses need to prepare various methods such as online, offline, individual and group methods to work effectively in any social situation. ABSTRACT: Introduction Pre- and postmenopausal women (PPW) experience physical and psychological changes with hormonal changes. Among Asian middle-aged women, family and culture affect suicidal ideation, and the suicide rate among this population is increasing. There are few existing research on suicidal ideation among Asian PPW. Aim We examined individual- and community-level factors that predict suicidal ideation among PPW. Method Large-scale panel data from 5,154 South Korean PPW aged 35-64 years were used in a series of multilevel logistic regression analyses to examine factors associated with suicidal ideation at individual and community levels. Results Among premenopausal women, religious beliefs, alcohol use, chronic disease, experience of violence, stress and depression were individual-level factors. Locational depression and locational counselling for stress were community-level factors. Among postmenopausal women, experience of violence, stress, depression and perceived health status were individual level factors, and locational counselling for depression was a community level factor. Discussion Suicidal ideation among PPW is affected by both individual and community level factors. Nurses must comprehensively determine what risk factors affect suicidal ideation through various intervention methods-including online, offline, individual and group methods-while considering socio-economic situations. Implications for Practice Mental health nurses should provide targeted biopsychosocial interventions targeting psychosocial and physical problems and promoting the use of community resources to reduce PPW's suicidal ideation.

Adolescent girls' stress responses as prospective predictors of self-injurious thoughts and behaviors: A person-centered, multilevel study

Adolescent risk for self-injurious thoughts and behaviors (STBs) involves disturbance across multiple systems (e.g., affective valence, arousal regulatory, cognitive and social processes). However, research integrating information across these systems is lacking. Utilizing a multiple-levels-of-analysis approach, this person-centered study identified psychobiological stress response profiles and linked them to cognitive processes, interpersonal behaviors, and STBs. At baseline, adolescent girls (N = 241, Mage = 14.68 years, Range = 12-17) at risk for STBs completed the Trier Social Stress Test (TSST), questionnaires, and STB interviews. Positive affect (PA), negative affect (NA), and salivary cortisol (SC) were assessed before and after the TSST. STBs were assessed again during 3, 6, and 9 month follow-up interviews. Multitrajectory modeling of girls' PA, NA, and SC revealed four profiles, which were compared on cognitive and behavioral correlates as well as STB outcomes. Relative to normative, girls in the affective distress, hyperresponsive, and hyporesponsive subgroups were more likely to report negative cognitive style (all three groups) and excessive reassurance seeking (hyporesponsive only) at baseline, as well as nonsuicidal self-injury (all three groups) and suicidal ideation and attempt (hyporesponsive only) at follow-up. Girls' close friendship characteristics moderated several profile-STB links. A synthesis of the findings is presented alongside implications for person-centered tailoring of intervention efforts.

Child maltreatment, recent stressful life events, and suicide ideation: A test of the stress sensitivity hypothesis

BACKGROUND

Exposure to child maltreatment is a well-known risk factor for suicide ideation among adolescents. Recent stressful life events may also contribute to this risk. However, the association between these risk factors is unclear in the etiology of suicide ideation for adolescents from socio-economically disadvantaged backgrounds.

OBJECTIVE

The present study tested the stress generation and stress sensitivity hypotheses in relation to child maltreatment, recent stressful life events (in the past year), and suicide ideation (in the past two weeks).

PARTICIPANTS AND SETTING

We utilized a sample of diverse, socioeconomically disadvantaged, depressed adolescent girls (N = 175) who were part of a depression treatment intervention.

RESULTS

Child maltreatment was significantly associated with adolescent suicide ideation, β = .40, p < .001. Results supported the stress sensitivity hypothesis, in that exposure to interpersonal stressors in the past year exacerbated the association between child maltreatment and adolescents' suicide ideation, β = .18, p < .05. We found evidence for a protective factor, cognitive reappraisal, in the association between stressful life events and suicide ideation, β = -.15, p < .05.

CONCLUSIONS

These findings have several implications for clinical practice and suicide prevention with adolescent girls, and contribute to the extant literature on the role of chronic and acute stress in the etiology of adolescent suicide ideation.

Risk and Protective Factors of Child-to-Parent Violence: A Comparison Between Physical and Verbal Aggression

Child-to-parent violence (CPV) is a social problem that remains vastly understudied compared with other forms of family violence. The aim of this study is to identify family and child risk and protective factors of CPV, and to investigate whether they differentially predict physical and verbal parent-directed violence among boys and girls. Predictors include parenting behavior during childhood (physical and verbal violence, warmth, monitoring) and respondents' individual characteristics (suicidal ideation, self-control, problematic substance use). Data were examined from a large representative sample of ninth graders (N = 6,444) in Lower Saxony, Germany. Bivariate analyses showed that female adolescents were more likely to aggress verbally, while no gender differences were found for physical CPV. Multilevel logistic regression models revealed that direct experiences of parental physical and verbal violence during childhood were among the strongest predictors of physical and verbal CPV, both among males and females. While parental monitoring was not significantly associated with CPV, parental warmth protected girls from physical parent-directed aggression. Furthermore, high self-control was protective against verbal CPV as well as boys' physical CPV, while problematic substance use predicted physical violence toward parents in both sexes but only boys' verbal CPV. Suicidal ideation was a risk factor of aggression in males only. Except for parental warmth, the importance of risk and protective factors did not substantially vary across child gender. These findings broaden our understanding of different family and child-related factors that either promote or prevent CPV. Specifically, they point to the importance of the parenting context and especially harsh discipline practices for the occurrence of both physical and verbal CPV.

Depression, Suicidal Ideation and Perceived Stress in Italian Humanities Students: A Cross-Sectional Study

Mental health issues are common among university students. Nevertheless, few studies focused on Italian students. This study aimed to assess prevalence and associated factors of perceived stress (PS), depressive symptoms (DS) and suicidal ideation (SI) in an Italian sample. A cross-sectional study was conducted amongst a convenience sample of students in humanities field (2018). Questionnaires were self-administered. Outcomes were assessed through Beck Depression Inventory-II (DS, SI) and Perceived Stress Scale (PS). Multivariable regressions were performed (p-value < 0.05 significant; sample size = 203). DS and SI prevalence was 30.6% and 8.8%. PS median score was 20 (IQR = 11), 87.7% reported moderate/severe PS. DS likelihood was increased by psychiatric disorders family history and not attending first year of course and decreased by not thinking that university hinders personal activities. Chronic disease and higher stress score increased SI probability; good/excellent family cohesion reduced it. Being female, thinking that university hinders resting/relaxing, seeing a psychologist/psychiatrist were positively associated with PS; having no worries about future was negatively associated. A high prevalence of mental health issues was reported, with miscellaneous associated factors that were linked to both private and social aspects. Universities must be aware of this to provide efficient preventive measures.

Life Stress and Suicide in Adolescents

Stress exposure is central to theories of suicide. To advance understanding of the relation between stress and suicide, we examined whether specific, theoretically-pertinent life stressors were differentially related to suicidal thinking versus suicidal behaviors among hospitalized adolescents. Participants were 197 (144 female) adolescents aged 13 to 19 years old (M = 15.61, SD = 1.48) recruited from an acute residential psychiatric treatment program. Participants were categorized into mutually exclusive groups: psychiatric controls (n = 38) with no lifetime history of suicide ideation or suicide attempts, suicide ideators (n = 99) with current ideation and no lifetime attempts, and suicide attempters (n = 60) with a lifetime history of suicide ideation and at least one attempt in the past month. Adolescents completed the Stress and Adversity Inventory for Adolescents (Adolescent STRAIN), which assessed life events and chronic difficulties occurring in five social-psychological categories: Interpersonal Loss, Physical Danger, Humiliation, Entrapment, and Role Change/Disruption. Additionally, they completed a structured interview and symptom questionnaires to capture concurrent psychopathology. Controlling for demographic and clinical covariates, only Interpersonal Loss events distinguished attempters from psychiatric controls (OR = 2.27) and ideators (OR = 1.49); no events or difficulties differentiated ideators from controls. These effects persisted when analyses were restricted to single attempters and when events following the most recent attempt were excluded. The findings elucidate potential social-environmental triggers of suicide. Ultimately, this may improve the identification of ideators most likely to make an attempt, enabling the deployment of targeted early interventions.

Association of Childhood Maltreatment With Suicide Behaviors Among Young People: A Systematic Review and Meta-analysis

Importance

Children and young people's reports of experiences of adverse childhood events have increased in recent years, and this trend has been associated with an elevated risk for suicide behaviors. However, a systematic review and meta-analysis is needed to confirm the significance of this association in young people.

Objective

To quantify the association between core types of childhood maltreatment, including sexual, physical, and emotional abuse and/or neglect and suicide behaviors in children and young adults.

Data Sources

Medline, PsychInfo, Embase, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health) databases were searched from January 1, 1980, until December 31, 2019. The reference lists of all the included studies were also checked.

Study Selection

Quantitative studies that focused on the association between core types of childhood abuse and/or neglect and suicide ideation, plans, and attempts.

Data Extraction and Synthesis

Data were extracted by 2 independent raters. Publication bias and risk of bias across studies were assessed. Meta-analyses using random-effect models were applied, and heterogeneity was quantified using the I2 statistic. Data were analyzed from January to May 2020 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines.

Main Outcomes and Measures

The association between core types of childhood maltreatment and suicide behaviors.

Results

Seventy-nine studies with 337 185 young individuals (mean [SD] age, 15.67 [2.11] years; 63.19% female) were included. The findings demonstrated that sexual abuse (odds ratio [OR], 3.41; 95% CI, 2.90-4.00), physical abuse (OR, 2.18; 95% CI, 1.75-2.71), emotional abuse (OR, 2.21; 95% CI, 1.37-3.57), emotional neglect (OR, 1.93; 95% CI, 1.36-2.74), physical neglect (OR, 1.79; 95% CI, 1.27-2.53), and combined abuse (OR, 3.38; 95% CI, 2.09-5.47) were significantly associated with higher rates of suicide attempts. Core types of childhood maltreatment were also associated with as much as 2.5-fold greater odds for suicide ideation, and sexual abuse with a 4.0-fold increase for suicide plans. Studies based on community samples (β [SE] = -1.68 [0.79]; P = .04) or with lower methodological quality (β [SE] = -2.86 [1.30]; P = .03) were associated more strongly with suicide attempts in those reporting experiences of sexual abuse, whereas young age was associated with both suicide attempts (β [SE] = -0.59 [0.27]; P = .03) and ideation (β [SE] = -0.41 [0.18]; P = .03).

Conclusions and Relevance

These findings suggest that policy actions should focus on raising public awareness and offering proactive suicide prevention therapies for children and young adults who have experienced abuse and/or neglect.

Suicidal Ideation in Adolescence: A Perspective View on the Role of the Ventromedial Prefrontal Cortex

Suicide in adolescence is a worldwide issue, and it continues to present a serious problem in terms of its prevention. Among the various aspects of suicide, a very interesting area of research is represented by suicidal ideation. Recently, neuroimaging-based methods have made it possible to study the cognitive processes involved in several social situations and clinical conditions. This theoretical perspective article with an interdisciplinary approach integrates evidence from developmental psychology and social neuroscience with the aim of investigating the role of the brain area responsible for regulating negative emotions during the cognitive processes of suicidal ideation: the ventromedial prefrontal cortex. By highlighting the role of brain areas in the few studies published so far, it is possible to develop perspectives of considerable impact. Studying and understanding the role of brain areas involved in suicidal thoughts in adolescents could facilitate the creation of new perspectives on prevention programs and interventions.

Function and Psychotherapy of Chronic Suicidality in Borderline Personality Disorder: Using the Reinforcement Model of Suicidality

Although great advancements in evidence-based therapies, chronic suicidal patients with borderline personality disorder (BPD) still challenge our mental health system. While BPD patients continue suffering from distress and aversive emotions, therapists and relatives feel often stunned and helpless when confronted with suicidality resulting in interruption of therapies, repeated presentations to emergency rooms and referrals to hospitals. Reviewing the current knowledge of the functions and background of non-suicidal self-injury, we learned that reinforcement mechanisms play an important role to understand why individuals act in deliberate self-mutilation. While individual motives for non-suicidal self-injury and suicidal behavior including suicidal ideations can differ, the principle mechanisms appear to be transferrable. Elucidating the individual motives and function of suicidal behavior is an important therapeutic step, giving us access to very central maladaptive schemes and false believes that we need to address in order to reduce chronic suicidality in BPD patients. This Perspective article aims to give a better idea of what is behind and what are the differences between non-suicidal self-injury, suicidal ideations and suicide attempts. It further integrates recent developments of behavioral science in a reinforcement model of suicidality that can provide therapists a practical armamentarium in their work with chronic suicidal clients.

Exposure to Traumatic Events and Development of Psychotic Symptoms in a Prison Population: A Network Analysis Approach

Previous studies consistently observed an association between exposure to traumatic events and psychotic symptoms. However, little is known about the differential impact of distinct traumatic events and the role of general symptoms in mediating this relationship. Thus, our study aimed to explore the differential association of several traumatic events to the psychotic symptoms in a sample of prisoners and whether this association is mediated by general symptoms. The total sample from the Survey of Psychiatric Morbidity Among Prisoners in England and Wales (N = 3039; 75.4% male) was used. Participants completed a list of traumatic events experienced before reclusion, the Psychosis Screening Questionnaire, Clinical Review Schedule-Revised. Network analysis was used to estimate the network of interactions between traumatic events and general and psychotic symptoms. Shortest paths analysis was performed to identify the different development trajectories. Results suggested that memory problems, compulsions, and irritability might be key mediating symptoms for most traumatic events. However, sexual abuse showed alternative mediators that might be specific of this traumatic event. Finally, the traumatic events, suffered from violence at work, separation/divorce and been homeless showed direct associations with specific psychotic symptoms.

A Scientometric Study on Depression among University Students in East Asia: Research and System Insufficiencies?

Given that mental health issues are acute in Asian countries, particularly Japan and Korea, and university students are more vulnerable to depression than the general population, this study aims to examine the landscapes of scientific research regarding depressive disorders among university students and evaluate the effectiveness of international collaboration and funding provision on the scientific impact in Korea, Japan, and China. Based on articles retrieved from the Web of Science database during the period 1992–2018, we found that the number of scientific publications, international collaborations, and allocated funds regarding depressive disorder among university students in China (97 articles, 43 international collaborations, and 52 funds provided, respectively) overwhelmingly surpassed the case of Korea (37 articles, 12 international collaborations, and 15 funds provided, respectively) and Japan (24 articles, 5 international collaborations, and 6 funds provided, respectively). The differences in collaboration patterns (p-value < 0.05) and the proportion of allocated funds (p-value < 0.05) among Korea, Japan, and China were also noted using Fisher’s exact test. Based on the Poisson regression analysis, China’s associations of scientific impact with international collaboration (β = −0.322, p-value < 0.01) and funding provision (β = −0.397, p-value < 0.01) are negative, while associations of the scientific impact and scientific quality with funding provision and international collaboration were statistically insignificant. These findings hint that Korea and Japan lacked scientific output, diversity in research targets, international collaboration, and funding provision, compared to China, but the quality of either China’s internationally collaborated or funded articles was contentious. As a result, policymakers in Korea and Japan are suggested to raise the importance of mental health problems in their future policy planning and resource distribution. Moreover, it would be advisable to establish a rigorous system of evaluation for the quality of internationally collaborated and funded studies in order to increase scientific impact and maintain public trust, especially in China.

Suicidality in a Community Sample of Early Adolescents: A Three-Phase Follow-Up Study

The aim of the study was to collect data on suicidal ideation and suicidal risk prevalence in a three-phase epidemiological study. In the first phase, 1,514 participants (720 boys; mean-age = 10.2) filled out the Children's Depression Inventory (CDI) and other psychopathological tests. 562 individuals (mean-age = 11.3) were selected to participate in the second phase as at-risk individuals of emotional disorders or as controls, and the CDI and the Mini-International Neuropsychiatric Interview for Children and Adolescents (M.I.N.I.-Kid) were administered. In the third phase the participants (245; mean-age = 13.5) filled out the Youth's Inventory-4. The results of the CDI indicated that 15.9% of the participants showed suicidal ideation in the first phase, and 18.2% and 18.0% in the second and third phases, respectively. 33.0% of the participants persisted at 1 year of follow-up with suicidal ideation. The M.I.N.I.-Kid showed 12.2% past suicidal risk and a current risk of 2.4%. The current suicidal risk was mainly related to depressive disorders (OR 30.3). Predictors of current suicidal risk for boys included having previous depressive symptoms. For girls predictors included having previous anxiety and obsessive-compulsive symptoms, suicidal ideation and lower socioeconomic status. Spanish early adolescents had relevant rates of suicidal behavior; thus, it is important to create and apply prevention programs that consider the risk factors.

Homicide Survivorship and Suicidality Among Adolescents

Homicide survivorship is linked to depression and trauma symptoms among adolescents, but little is known about associations with suicidality and how these associations intersect with other childhood adversities. This study examined the prevalence of homicide survivorship and associations with suicidality and childhood aversities among a population-based sample of youth using the Healthy Allegheny Teen Survey, a county-wide representative survey of 1,609 youth aged 14 to 19 in Allegheny County, Pennsylvania. Logistic regression models examined associations between homicide survivorship and suicidality, adjusting for (a) demographics and (b) demographics and childhood adversities. In all, 13% of youth were homicide survivors. Black youth experienced a disproportionate burden of traumatic loss. Homicide survivorship was associated with suicide attempts and childhood adversities. Closer attention to the impact of homicide survivorship on youth, mental health sequelae, and co-occurrent childhood adversities may guide interventions to recognize and support youth following traumatic loss.

Does higher-than-usual stress predict nonsuicidal self-injury? Evidence from two prospective studies in adolescent and emerging adult females

BACKGROUND

Nonsuicidal self-injury (NSSI) is highly prevalent among adolescent and emerging adult females. Most studies examining the relationship between stress and NSSI largely have relied on aggregate self-report measures of stress and between-person models. Using data from two prospective samples, this manuscript tests the hypothesis that within-person models of NSSI provide better clinical markers of risk for NSSI than between-person models of NSSI.

METHODS

Two samples (Sample 1: 220 high-risk girls, M age = 14.68, SD = 1.36, baseline assessment and 3-month follow-ups for 18 months; Sample 2: 40 emerging adult females with a history of NSSI, M age = 21.55, SD = 2.14, 14 days with daily retrospective reports) were followed prospectively and completed validated measures of stress and NSSI. Models were adjusted for age and depression.

RESULTS

In Sample 1, a within-person model demonstrated that higher-than-usual (but not average) stress levels predicted NSSI within the same 3-month wave. In Sample 2, results from a within-person model with daily diary assessment data showed that higher-than-usual stress (but not average daily stress) predicted same-day NSSI.

CONCLUSIONS

Together, our results suggest that higher-than-usual stress, relative to one's typical stress level, but not average stress levels, signals times of enhanced risk for NSSI. These results highlight the clinical utility of repeated assessments of stress.

Association between perinatal depressive symptoms and suicidal risk among low-income South African women: a longitudinal study

PURPOSE

The aim of this study was to assess the association between depressive symptoms and suicidal risk over time among perinatal women at risk for depression antenatally, and assess modifying effects of age, perinatal stage and depressive symptom trajectory.

METHODS

A total of 384 adult pregnant women were recruited from two antenatal clinics in an informal settlement near Cape Town, South Africa, and followed up at eight months gestation, and at 3- and 12-month postpartum. The MINI 6.0 Suicidality module and the Hamilton Depression Rating Scale (HDRS) were used to measure suicidal risk and depression, respectively. Generalised Estimating Equations were used to assess the association between change in depressive symptoms from one assessment to the next (predictor) and change in suicide score or change in suicidal risk (score ≥ 9) (outcomes).

RESULTS

HDRS scores were positively correlated with suicide score (95% CI 0.35, 0.78; p < 0.001), and with odds of being at moderate risk for suicide, after controlling for risk of suicide at the previous assessment (adjusted odds ratio = 1.15; 95% CI 1.09, 1.22; p < 0.001). Age was a significant effect modifier: change in HDRS scores was not associated with change in suicide scores among participants aged 35-45 years. Secondary analyses indicated that a decrease in HDRS score was associated with a decrease in suicide scores, but an increase in HDRS score was not associated with change in suicide score.

CONCLUSIONS

Depression and suicide are overlapping but relatively independent phenomena, especially among older or more chronically depressed perinatal women.

A Scoping Review of Evidence-Based Interventions for Adolescents with Depression and Suicide Related Behaviors in Low and Middle Income Countries

Depression is the number one cause of disability for adolescents. Moreover, depression is the strongest predictor for suicide, which is the second cause for death among adolescents worldwide. A total of 22 RCTs conducted in 14 different LMICs have been reviewed. This is a significant effort to provide mental health services for adolescents in LMICs. However, considering that 2/3 of the world's countries meet criteria for LMIC status and 75% of suicides occur in LMICs, more research addressing both understanding and intervention/prevention of depression and suicide must be conducted in these countries.

Examining the Association between Weapon Carrying on School Property and Suicide Attempt among Adolescents in the United States

Suicidal behaviors among adolescents in the United States are the second leading cause of death and has been steadily increasing over the years. Although access to and possession of a weapon may facilitate the transition from suicidal ideation to a suicide attempt, few studies have examined the association between weapon carrying and suicide attempts among adolescents. The objective of this study was to examine the association between weapon carrying on school property and suicide attempt among adolescents. Data for this study came from the 2017 Youth Risk Behavior Surveillance System. A sample of 14,547 adolescents aged 14-18 years old (50.5% female) was analyzed using logistic regression. Of the 14,547 adolescents, 4% carried a weapon on school property, and 7.7% attempted suicide during the past 12 months. In the multivariate logistic regression, adolescents who reported carrying a weapon on school property had more than double the odds of attempting suicide when compared to their counterparts who did not carry a weapon on school property. Other significant predictors of suicide attempt include sexual minority, history of forced sexual intercourse, school bullying and cyberbullying victimization, feeling sad or hopeless, and substance use. Examining the association between weapon carrying and suicide attempt among adolescents would contribute to early identification of adolescents who are likely to engage in suicidal behaviors.

Adolescent Suicide as a Failure of Acute Stress-Response Systems

Suicide is the second leading cause of death worldwide for adolescents. Despite decades of research on correlates and risk factors for adolescent suicide, we know little about why suicidal ideation and behavior frequently emerge in adolescence and how to predict, and ultimately prevent, suicidal behavior among youths. In this review, we first discuss knowledge regarding correlates, risk factors, and theories of suicide. We then review why adolescence is a period of unique vulnerability, given changing biology and social network reorganization. Next, we present a conceptual model through which to interpret emerging findings in adolescent suicide research. We suggest that a promising area for future research is to examine adolescent suicide as a failure of biological responses to acute stress in the proximal moments of a suicidal crisis. After reviewing initial evidence for this conceptualization, we review future directions for studies on adolescent suicide.

Implicit Identification with Death Predicts Suicidal Thoughts and Behaviors in Adolescents

Prior research indicates that adults' implicit identification with death can be used to predict suicidal thoughts and behaviors (STBs) in the community. However, no studies have examined whether this effect is found among adolescents-a group for whom suicide is the 2nd leading cause of death. The current study tested the utility of implicit identification with death, using a Death Implicit Association Test (IAT), for detecting and predicting STBs in adolescents. Participants were 141 adolescents 12-19 years of age (81.6% female, 74.5% White) with a current psychiatric disorder and/or currently receiving outpatient psychiatric treatment. All participants completed the Death IAT and self-report measures of STBs at baseline, as well as self-report measures of STBs at 6-month and 1-year follow-ups. At baseline, stronger implicit identification with death (higher Death IAT score) was related to greater suicide ideation (SI) frequency, severity, and duration, but did not differ based on suicide attempt history. Prospectively, higher Death IAT scores predicted any occurrence (but not frequency) of SI over the subsequent year, but not when controlling for prior SI. Death IAT scores were higher among adolescents with prior attempts who reattempted suicide over the follow-up. Examination of stimuli-level results suggested that Death IAT differences may be driven by responses on trials with specific words, including suicide and die. Implicit identification with death may be a useful behavioral indicator of suicide risk in adolescents. Preliminary findings suggest that the Death IAT may aid in predicting STBs among youth receiving outpatient treatment.

Biological responses to acute stress and suicide: A review and opportunities for methodological innovation

Purpose of Review

While rates of other medical illnesses have declined over the past several decades, rates of suicide have increased, particularly among adolescents. Prior research on biological underpinnings of suicide risk has remained limited. In this review, we describe a recent model conceptualizing suicide as a failure of biological responses to acute stress. According to this model, youth who fail to mount an adaptive stress response following exposure to a stressor are at acute risk for suicide.

Recent Findings

Although much more research is needed, early evidence suggests that abnormal biological responses to acute stress, such as altered autonomic nervous system activity and altered hypothalamic-pituitary-adrenal axis function, may underlie risk for suicide, particularly during the transition to adolescence.

Summary

Overall, initial evidence supports a link between biological responses to acute stress and suicide risk. However, future work that incorporates makers of other biological and environmental systems will sharpen our understanding of who is at suicide risk and when this risk is highest.

Reciprocal Associations Between Adolescent Girls' Chronic Interpersonal Stress and Nonsuicidal Self-Injury: A Multi-wave Prospective Investigation

PURPOSE

Nonsuicidal self-injury (NSSI) is associated with increased risk of suicide attempts. Theories of NSSI assert interpersonal stress as a common risk factor for, and perhaps consequence of, NSSI. Prior research has not examined reciprocal associations between chronic interpersonal stress and NSSI. This study used a multiwave, prospective design to address this gap in a sample of adolescent girls, a group with elevated risk for both chronic interpersonal stress and NSSI. Pubertal development was examined as a moderator of the reciprocal associations.

METHODS

Adolescent girls (N = 220; ages 12-16, M age = 14.69 years) at heightened risk for NSSI completed a baseline assessment and follow-up assessments over 18 months, divided into two 9-month epochs (Time 1 and 2). Pubertal development was assessed via self- and parent-report. Chronic interpersonal stress was assessed using a semistructured interview at the end of each time period. NSSI was measured using a semistructured clinical interview every 3 months within both time periods to enhance accurate reporting.

RESULTS

Path models revealed that chronic romantic stress during Time 1, but not peer or parent-child stress, predicted NSSI during Time 2 among girls with more advanced pubertal development. Moreover, NSSI during Time 1 predicted higher levels of chronic romantic and parent-child stress during Time 2.

CONCLUSIONS

Results revealed a reciprocal relationship between chronic romantic stress and engagement in NSSI. Further, this association may be best understood in the context of pubertal development.

HPA axis response and psychosocial stress as interactive predictors of suicidal ideation and behavior in adolescent females: a multilevel diathesis-stress framework

Prior studies suggest that hypothalamic-pituitary-adrenal (HPA) axis stress response is a relatively stable risk factor for suicidal behavior in adults, and also that fluctuations in developmentally salient social stress (i.e., peer stress) predict acute suicidal ideation and behavior in adolescent females. Here, we test the hypothesis that periods of high peer stress are prospectively associated with concurrent episodes of suicidal ideation and behavior, but that abnormal cortisol responses to stress at baseline act as a diathesis that strengthens this stressor-suicidality link, using a longitudinal, multi-wave study design. We measured cortisol responses to an adolescent modification of the Trier Social Stress Test in 220 adolescent females recruited for mental health concerns, and measured stress (peer, academic, and mother-child) and suicidal ideation and behaviors repeatedly across 18 months. Logistic multilevel models revealed the predicted interaction between altered cortisol response and elevated periods of peer stress in predicting suicidal behavior, but not ideation. Higher-than-usual peer stress predicted suicidal ideation regardless of HPA function, but predicted suicide attempt only among those with blunted cortisol responses. Results suggest that peer stress serves to trigger suicidal ideation among female youth, but only triggers suicidal behavior among those with blunted cortisol reactivity.