Why do adolescents attempt suicide? Insights from leading ideation-to-action suicide theories: a systematic review

Suicide is a leading cause of death among adolescents, and recent suicide theories have sought to clarify the factors that facilitate the transition from suicide ideation to action. Specifically, the Interpersonal Theory of Suicide (IPTS), Integrated Motivational-Volitional Model (IMV), and Three Step Theory (3ST) have highlighted risk factors central to the formation of suicidal ideation and suicidal behaviors, which is necessary for suicide death. However, these models were initially developed and tested among adults, and given core socioemotional and neurodevelopmental differences in adolescents, the applicability of these models remains unclear. Directly addressing this gap in knowledge, this systematic review aimed to (1) describe the evidence of leading ideation-to-action theories (i.e., IPTS, IMV, 3ST) as they relate to suicide risk among adolescents, (2) integrate ideation-to-action theories within prevailing biological frameworks of adolescent suicide, and (3) provide recommendations for future adolescent suicide research. Overall, few studies provided a complete test of models in adolescent samples, and empirical research testing components of these theories provided mixed support. Future research would benefit from integrating neurodevelopmental and developmentally sensitive psychosocial frameworks to increase the applicability of ideation-to-action theories to adolescents. Further, utilizing real-time monitoring approaches may serve to further clarify the temporal association among risk factors and suicide.

Back to the roots of perceived burdensomeness: The potential role of perceived contribution

BACKGROUND

The Interpersonal-Psychological Theory of Suicide (IPTS), identifies perceived burdensomeness as a critical factor in the development of suicidal ideation. Measurement of perceived burdensomeness using the INQ in research has predominantly focused on liability toward others. Recent studies have demonstrated the role of perceived contribution toward others as an aspect of perceived burdensomeness. This study proposes a hypothesized transactional model of perceived burdensomeness, in which perceived burdensomeness can be viewed as the balance between perceived contributions and perceived liability to others.

METHOD

Participants (n = 1112) were college students (M age = 18.86 years, SD = 1.50) who completed survey measures. Participants were predominantly cisgender women (73.6%), heterosexual (78.8%), and white (58.3%).

RESULTS

Perceived contribution was negatively associated with perceived burdensomeness, suicidal ideation, and psychological pain after controlling for perceived liability. Further, the difference between perceived contributions and perceived liability accounted for variability in suicidal ideation after controlling for INQ perceived burdensomeness.

DISCUSSION

The inclusion of perceived contribution as an element of perceived burdensomeness may offer new opportunities for clinical formulation and intervention. Future research is needed to further evaluate the proposed transactional model of perceived burdensomeness.

Perceived burdensomeness and thwarted belongingness as mediators of the relation between anxiety and suicidal ideation among adolescents

INTRODUCTION

Anxiety and suicidal ideation have been shown to be positively related in adolescents. However, less is known about the strength of this association across different types of anxiety or the mechanisms through which this relation exists. Joiner's interpersonal theory of suicide suggests that thwarted belongingness (TB) and perceived burdensomeness (PB) lead to suicidal ideation; these constructs may explain a pathway through which anxiety and suicidal ideation are related. It was hypothesized that TB would mediate the relation between social anxiety disorder (SAD) symptoms and suicidal ideation, and PB would mediate the relation between generalized anxiety disorder (GAD) symptoms and suicidal ideation.

METHODS

These longitudinal mediation models were assessed using data collected from 147 depressed adolescents, who were recently hospitalized for suicidal ideation or behavior, enrolled in a randomized controlled trial (RCT).

RESULTS

Consistent with study hypotheses, PB mediated the relation between GAD symptoms and suicidal ideation severity. However, TB did not mediate the relation between SAD symptoms and suicidal ideation severity.

CONCLUSION

These results suggest that screening for and addressing PB among youth with GAD may help reduce risk for suicidal behavior.

Familism moderates the association between parent-child conflict, interpersonal needs, and suicidal ideation among adolescents

Within the framework of the interpersonal theory of suicide, parent-child conflict in adolescence may be associated with suicidal ideation through increases in thwarted interpersonal needs (i.e., perceived burdensomeness and thwarted belongingness). Familism, a cultural value that emphasizes prioritizing familial interconnectedness and honor, may moderate the association between parent-child conflict and thwarted interpersonal needs. This study examined the relationship between parent-child conflict, familism, and suicidal ideation through the interpersonal theory of suicide. Participants were N = 250 psychiatrically hospitalized adolescents aged 12-17 years (Mage = 14.84, 60.8% female; 41.9% Hispanic, 21.5% African American/Black, 26.0% Caucasian). Participants completed survey and interview measures prior to discharge from psychiatric hospitalization. There was a significant conditional indirect effect of parent-child conflict on suicidal ideation through thwarted interpersonal needs [F (3, 246) = 54.41, p < .01], such that the strength of the indirect effects family conflict on suicidal ideation via thwarted interpersonal needs increased as familism increased. Findings indicate that the relationship between parent-child conflict and thwarted interpersonal needs may be exacerbated when levels of familism are also high. For youth who endorse high levels of familism, parent-child conflict may be particularly pernicious. Interventions targeting the family environment are needed to potentially improve adolescents' interpersonal functioning and protect against suicidal ideation.

Examining the integrated model of the interpersonal-psychological theory of suicide and intersectionality theory among Black male adolescents

INTRODUCTION

Guided by Opara et al.'s (2022), Integrated Model of the Interpersonal Psychological Theory of Suicide and Intersectionality Theory, the current study examined contextual stressors experienced disparately by Black youth (racial discrimination, poverty, and community violence) as moderators of the association between individual motivating factors for suicidal thoughts and behaviors (perceived burdensomeness, thwarted belongingness, and hopelessness) and active suicidal ideation.

METHOD

Participants were 457 Black adolescent boys (mean age = 15.31, SD = 1.26) who completed self-report surveys.

RESULTS

As predicted, the association between perceived burdensomeness and active suicidal ideation was significantly moderated by economic stress. In addition, the association between peer belongingness and suicidal ideation was significantly moderated by racial discrimination, but there were no moderating effects for school belongingness. Finally, the association between hopelessness and suicidal ideation was significantly moderated by both racial discrimination and witnessing community violence.

CONCLUSION

These findings highlight the need for research, interventions, and policy work devoted to using integrated approaches of individual and socioeconomically relevant patterns of suicidal thoughts and behaviors to support Black youth exposed to various forms of structural oppression.

Cultural Consensus Modeling to identify culturally relevant reasons for and against suicide among Black adolescents

INTRODUCTION

The development of evidence-based treatments relies on accurate theoretical frameworks sensitive to the lived realities of the populations from which they are derived. Yet, the perspectives of Black youth are vastly underrepresented in extant theories of suicidal behavior. Cultural Consensus Modeling provides an evidence-based approach for developing a culturally informed understanding of suicide risk among Black youth.

METHOD

Participants were 50 Black adolescents (Mage  = 16.20 years; 76.0% male) who completed Phase 1 of a Cultural Consensus Modeling study. Participants freely listed reasons for suicide and reasons for living among similar peer Black youth. Responses were synthesized and coded for major themes.

RESULTS

The most common reasons for suicide were racism (40%), depression (32%), poverty (26%), and bullying (22%). The most common reasons for living were family (58%), having a purpose or goals (36%), friends (30%), and hope for a better future (26%).

CONCLUSION

Responses highlighted issues of racism and social justice, depression, and poverty, as well as the protective role of relationships, living for the future, and contributing to Black empowerment. Future research should utilize Cultural Consensus Modeling to elevate the voices of Black youth, improving extant theories of suicide, and identifying unique mechanisms or opportunities for prevention.

The Burden of Not Belonging: A Qualitative Study of the Applicability of the Interpersonal Theory of Suicide Constructs of Belongingness and Burdensomeness to Ethnocultural Minoritized Youth

Guided by the Interpersonal Theory of Suicide (IPTS), this study aims to understand the applicability of the constructs of belongingness and burdensomeness and their relevance to suicide risk and mental health among ethnocultural minoritized youth. A qualitative exploratory study was conducted using five focus groups with 29 self-identified Latinx and Black adolescents aged 13-17 years to explore the meaning they ascribed to belongingness and burdensomeness. Views of social media related to these constructs were also explored. Template analysis was used to analyze the data. Themes highlighted dimensions such as caring, self-worth, and liability, congruent with the IPTS dimensions of belongingness and burdensomeness. Notably, new themes emerged reflecting the distinctive experiences of these populations, such as the importance of being true to themselves, the burden of not belonging to families, and cultural aspects of liability, highlighting dimensions not found in the existing IPTS theoretical constructs. Consideration of the diverse experiences of ethnocultural minoritized youth can strengthen theoretical constructs, clinical practice, and aid in developing intervention strategies to increase protective factors and decrease risk factors for suicide behaviors relevant to such youth.

Respiratory sinus arrhythmia, negative social interactions, and fluctuations in unmet interpersonal needs: A daily diary study

INTRODUCTION

This study examined daily fluctuations in the unmet interpersonal needs of thwarted belongingness and perceived burdensomeness in response to daily negative social interactions, as well as the moderating role of respiratory sinus arrhythmia (RSA) across adolescents at lower and higher risk for suicidal ideation.

METHODS

Fifty five adolescents with major depressive disorder (MDD, i.e., higher-risk group) and without MDD (i.e., lower-risk group) completed measures of resting RSA, and daily measures of negative social interactions, perceived burdensomeness, and loneliness, as a proxy for thwarted belongingness, for 10 consecutive days. Within-person analyses examined the association between daily negative social interactions and unmet interpersonal needs, and the moderating roles of RSA and higher-risk group status. Between-person analyses also examined the association between RSA and unmet interpersonal needs across groups.

RESULTS

At the within-person level, participants reported more unmet interpersonal needs on days when they reported more negative social interactions. At the between-person level, higher RSA was associated with decreased loneliness in both groups, and decreased burdensomeness among the higher-risk group.

CONCLUSIONS

Negative social interactions are associated with daily unmet interpersonal needs. Higher RSA may serve as a protective factor mitigating risk for unmet interpersonal needs, particularly burdensomeness, among adolescents at higher risk for suicidal ideation.

Longitudinal Relations Between Parenting Practices and Adolescent Suicidal Ideation in a High-Risk Clinical Sample: A Moderated Mediation Model

Parenting behaviors are associated with adolescent suicidal ideation (SI), but few studies have examined this relation longitudinally or investigated underlying mechanisms. We investigated a moderated mediation model to evaluate perceived burdensomeness as a mediator in the longitudinal relation between parenting behavior (warmth and verbal hostility) and adolescent SI. We hypothesized that this association would be particularly strong among adolescents with greater functional impairment. The sample included 147 adolescents (M_age = 14.9, Age Range = 12-18 years, 76.2% female) and a primary caregiver (M_age = 43.5, Age Range = 27-60 years, 81.4% female) enrolled in a clinical trial. Caregivers completed measures of warmth and verbal hostility (PCPR) and adolescents completed measures of functional impairment (CDI-2), perceived burdensomeness (INQ), and SI (SIQ-JR) at baseline, 12 and 18 months. Two moderated mediation path analyses, one for each parenting behavior, were conducted. Age, sex, treatment condition, baseline and 12-month SI, baseline perceived burdensomeness, and the alternate baseline parenting behavior were included as covariates. Neither model yielded a significant direct effect between baseline parental verbal hostility or warmth and 18-month SI. However, lower warmth and higher verbal hostility were positively associated with 18-month SI indirectly through greater 12-month perceived burdensomeness among youth with relatively higher levels of functional impairment. Perceptions of burdensomeness are a mechanism by which low parental warmth and high parental verbal hostility contribute to SI, but only among youth with greater functional impairment. Interventions to address youth perceptions of burdensomeness may be beneficial, particularly for the most highly impaired youth.

Family relationships and the interpersonal theory of suicide in a clinically suicidal sample of adolescents

In a sample of suicidal adolescents (N = 117), we sought to identify how adolescents' attachment to their parents related to a key mechanism of suicide from the Interpersonal Theory of Suicide (IPTS). We tested both attachment-anxiety and attachment-avoidance, to both mother- and father-figures as correlates of the IPTS construct, perceived burdensomeness (PB). In addition, we tested PB as a mediator between these attachment variables and adolescent suicide ideation in a path analysis. Our path analysis indicated both mother- and father-related attachment anxiety were associated with PB and PB was related to suicide ideation. We also found an indirect effect of father-related attachment anxiety on suicide ideation. This study provides empirical support for earlier systemic work that proposes how family relationships may influence an adolescent's suicidal ideation. Finally, we provide practical clinical suggestions for how therapists may implement a systemic framework to address a suicidal adolescent and their family relationships.

Psychometric Properties of the Interpersonal Needs Questionnaire-15 in Spanish Adolescents

BACKGROUND

Thwarted Belongingness (TB) and Perceived Burdensomeness (PB) are considered risk factors of suicide behavior in the Interpersonal Theory of Suicide and constitute the main factors of the Interpersonal Needs Questionnaire-INQ.

AIMS

The present study analyzes the internal consistency, construct validity, and invariance across sex and age of the INQ-15, which comprises two subscales, in a sample of Spanish community adolescents.

METHODS

Participants were 1,536 adolescents from 12 to 19 years old. The INQ-15, the total number of non-suicidal self-injuries (NSSI), the Hopelessness Scale, and the Purpose in Life Test-Adolescents (PIL-A) were used.

RESULTS

The INQ-15 showed good internal consistency for TB ( ω ¯ = 0.88) and PB ( ω ¯ = 0.78) subscales and construct and concurrent/discriminant validity in the whole sample. Both the PB and TB subscales showed a good fit { S B χ 2 ( 9 ) = 6.448, p = 0.694, CFI = 1.000, RMSEA = 0.000 [90% CI (0.000, 0.022)] and S B χ 2 ( 27 ) = 248.973, p = 0.000, CFI = 0.922, RMSEA = 0.073 [90% CI (0.065, 0.082)]}, respectively. Regarding the invariance analyses, we found (1) non-invariance in the PB subscale across sex groups and metric, scalar, and stric invariance across age groups, and (2) that it was not possible to perform the invariance analysis for the TB subscale across both sex and age because the fit was not adequate for both boys and 12-15 years old groups. Positive and significant relationships were found between the INQ-15 subscales and hopelessness and NSSI frequency, and negative and significant correlations with meaning in life.

CONCLUSIONS

The INQ-15 is a valid instrument for assessing TB and PB in Spanish adolescents. Future studies should analyze the invariance of this instrument in adolescents across sex and age.

Suicide Risk in Youth and Young Adults with Type 1 Diabetes: a Review of the Literature and Clinical Recommendations for Prevention

PURPOSE OF REVIEW

The manuscript reviews the extant literature on suicide-related thoughts and behaviors among youth and young adults with pediatric diabetes. This evidence is presented within the context of current theories of the etiology of suicidal behavior to highlight how diabetes may contribute to suicide risk, and to support providers in understanding the interplay between pediatric diabetes and suicide risk. The manuscript also reviews evidence-based approaches to suicide prevention suitable for use in pediatric healthcare settings, with suggestions for their application to this unique population.

RECENT FINDINGS

Several recent studies identify heightened rates of suicidal ideation, suicide attempts, and suicide among youth and young adults with pediatric diabetes, as compared with their peers without diabetes. Evidence-based suicide prevention approaches frequently emphasize the importance of reducing suicidal youths' access to potentially lethal means for suicidal behavior. This approach may require special considerations for youth with pediatric diabetes, due to their need to carry sufficient quantities of insulin and the dangers of inaccurate insulin dosing and/or overdose. Suggestions for suicide prevention for this population include risk screening as part of routine diabetes care, early prevention, education for youth and families, and provider awareness of risk factors, warning signs, and implications for diabetes care. Youth and young adults with diabetes reported elevated rates of suicide-related behaviors as compared with their peers without diabetes. Existing suicide prevention approaches may require substantial adaptation for use with youth and young adults with diabetes. Further research is needed to examine how to best prevent suicidal behaviors among this population.

Performance of the interpersonal needs questionnaire in adolescent clinical samples: Confirmatory factor analyses and evaluation of measurement invariance

OBJECTIVE

This study evaluated the factor structure, internal consistency reliability, construct and criterion validity, and measurement invariance of the Interpersonal Needs Questionnaire (INQ) among adolescents.

METHOD

Participants (N = 539) included three distinct samples of youth drawn from two outpatient psychology clinics and an inpatient psychiatric unit. The combined sample was 63.3% female and had a mean age of 14.95 years (SD = 1.31 years). All participants completed the INQ as well as measures of depressive symptoms and suicide ideation.

RESULTS

Confirmatory factor analyses indicated that the removal of three items from the thwarted belongingness subscale of the INQ was needed to achieve acceptable model fit. The resulting combined 12-item scale demonstrated good factor structure, internal consistency reliability, construct validity, and criterion validity. The modified 12-item INQ also demonstrated scalar invariance across subgroups defined by sex, race, and age.

CONCLUSIONS

Findings support the use of this reduced 12-item version of the INQ among adolescents. Youth may have difficulty accurately responding to changes in item valence; thus, future research with youth should consider using a 12-item version of the INQ that avoids valence changes within subscales.

Perceived burdensomeness and neural responses to ostracism in the Cyberball task

Previous studies have identified the brain correlates of social pain processing during ostracism. However, the affective response to ostracism may vary according to individual differences in interpersonal needs and subsequent social actions. Despite this relationship, how the neural processes underlying ostracism may be modulated by interpersonal needs to regulate prosocial behaviors remains unknown. Here, in an fMRI study of 64 adults performing the Cyberball task, we quantified ball catching and tossing response time (RT) as a behavioral measure of participants' willingness to seek and reciprocate social interactions. Neural activations to social exclusion were identified and characterized in relation to individual differences in behavioral performance and perceived burdensomeness (PB), a measure of interpersonal needs. The results showed that social exclusion elicited activity in the anterior insula, middle frontal gyrus, postcentral gyrus, and dorsomedial prefrontal cortex, replicating previous studies on ostracism. Importantly, those with higher PB also exhibited greater brain activations to exclusion as well as reduced prosocial behaviors, as reflected by slower ball catching and tossing RT in the Cyberball task. Taken together, these findings suggest that emotional distress in ostracism may increase with PB, resulting in stronger neural responses to social pain and behavioral avoidance of social interactions.