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1.  Smoking Initiation, Tobacco Product Use, and Secondhand Smoke Exposure Among General Population and Sexual Minority Youth, Missouri, 2011–2012 
Research indicates disparities in risky health behaviors between heterosexual and sexual minority (referred to as LGBQ; also known as lesbian, gay, bisexual, queer, and questioning) youth. Limited data are available for tobacco-use–related behaviors beyond smoking status. We compared data on tobacco age of initiation, product use, and secondhand smoke exposure between general population and LGBQ youth.
Data for general population youth were from the statewide, representative 2011 Missouri Youth Tobacco Survey, and data for LGBQ youth were from the 2012 Out, Proud and Healthy survey (collected at Missouri Pride Festivals). Age-adjusted Cochran-Mantel-Haenszel tests were used to examine differences between general population (N = 1,547) and LGBQ (N = 410) youth, aged 14 to 18 years. Logistic regression models identified variables associated with current smoking.
The 2 groups differed significantly on many tobacco-use–related factors. General population youth initiated smoking at a younger age, and LGBQ youth did not catch up in smoking initiation until age 15 or 16. LGBQ youth (41.0%) soon surpassed general population youth (11.2%) in initiation and proportion of current smokers. LGBQ youth were more likely to use cigars/cigarillos, be poly-tobacco users, and be exposed to secondhand smoke (SHS) in a vehicle (for never smokers). Older age (odds ratio [OR] = 1.39, 95% confidence interval [95% CI] = 1.18–1.62), female sex (OR = 1.64, 95% CI = 1.13–2.37), LGBQ identity (OR = 3.86, 95% CI = 2.50–5.94), other tobacco product use (OR = 8.67, 95% CI = 6.01–12.51), and SHS exposure in a vehicle (OR = 5.97, 95% CI = 3.83–9.31) all significantly increased the odds of being a current smoker.
This study highlights a need for the collection of data on sexual orientation on youth tobacco surveys to address health disparities among LGBQ youth.
PMCID: PMC4082434  PMID: 24995655
2.  Measurement Noninvariance of Safer Sex Self-Efficacy Between Heterosexual and Sexual Minority Black Youth 
Black and lesbian, gay, bisexual, or questioning (LGBQ) youth in the United States are disproportionately affected by HIV and other sexually transmitted diseases (STDs). Although self-efficacy is strongly, positively associated with safer sex behaviors, no studies have examined the validity of a safer sex self-efficacy scale used by many federally funded HIV/STD prevention programs. This study aims to test factor validity of the Sexual Self-Efficacy Scale by using confirmatory factor analysis (CFA) to determine if scale validity varies between heterosexual and LGBQ Black youth.
The study uses cross-sectional data collected through baseline surveys with 226 Black youth (15 to 24 years) enrolled in community-based HIV-prevention programs. Participants use a 4-point Likert-type scale to report their confidence in performing 6 healthy sexual behaviors. CFAs are conducted on 2 factor structures of the scale. Using the best-fitting model, the scale is tested for measurement invariance between the 2 groups.
A single-factor model with correlated errors of condom-specific items fits the sample well and, when tested with the heterosexual group, the model demonstrates good fit. However, when tested with the LGBQ group, the same model yields poor fit, indicating factorial noninvariance between the groups.
The Sexual Self-Efficacy Scale does not perform equally well among Black heterosexual and LGBQ youth. Study findings suggest additional research is needed to inform development of measures for safer sex self-efficacy among Black LGBQ youth to ensure validity of conceptual understanding and to accurately assess effectiveness of HIV/STD prevention interventions among this population.
PMCID: PMC5014365  PMID: 27617061
sexual behavior; self-efficacy; sexual orientation; HIV/AIDS; prevention
3.  Exploring lesbian, gay, bisexual, and queer (LGBQ) people’s experiences with disclosure of sexual identity to primary care physicians: a qualitative study 
BMC Family Practice  2015;16:175.
It has been demonstrated that health disparities between lesbian, gay, bisexual and queer (LGBQ) populations and the general population can be improved by disclosure of sexual identity to a health care provider (HCP). However, heteronormative assumptions (that is, assumptions based on a heterosexual identity and experience) may negatively affect communication between patients and HCPs more than has been recognized. The aim of this study was to understand LGBQ patients’ perceptions of their experiences related to disclosure of sexual identity to their primary care provider (PCP).
One-on-one semi-structured telephone interviews were conducted, audio-recorded, and transcribed. Participants were self-identified LGBQ adults with experiences of health care by PCPs within the previous five years recruited in Toronto, Canada. A qualitative descriptive analysis was performed using iterative coding and comparing and grouping data into themes.
Findings revealed that disclosure of sexual identity to PCPs was related to three main themes: 1) disclosure of sexual identity by LGBQ patients to a PCP was seen to be as challenging as coming out to others; 2) a solid therapeutic relationship can mitigate the difficulty in disclosure of sexual identity; and, 3) purposeful recognition by PCPs of their personal heteronormative value system is key to establishing a strong therapeutic relationship.
Improving physicians’ recognition of their own heteronormative value system and addressing structural heterosexual hegemony will help to make health care settings more inclusive. This will allow LGBQ patients to feel better understood, willing to disclose, subsequently improving their care and health outcomes.
PMCID: PMC4675062  PMID: 26651342
Sexual identity; Heteronormativity
4.  The Influence of Intersecting Identities on Self-Harm, Suicidal Behaviors, and Depression among Lesbian, Gay, and Bisexual Individuals 
Individuals with lesbian, gay, and bisexual (LGB) identities have higher prevalence of self-directed violence, but very little is known about racial/ethnic differences among LGB populations. This study aimed to examine racial/ethnic differences in self-harm, suicidal ideation, suicide attempt, and depression among LGB and heterosexual emerging adults. Data are compiled from the Fall 2008 and Spring 2009 National College Health Assessment and limited to respondents within emerging adulthood (ages 18-24) who indicated their sexual orientation and racial/ethnic identities (n=89,199). Within each racial/ethnic group, LGB individuals were significantly more likely to report self-harm, suicidal ideation, suicide attempt, and depression than non-LGB individuals.
PMCID: PMC4176776  PMID: 25250405
5.  Suicidal Ideation among Racial/Ethnic Minorities: Moderating Effects of Rumination and Depressive Symptoms 
Among emerging adults and college students, racial and ethnic minorities experience greater risk for suicidal ideation and behavior than their White counterparts. Research has identified numerous cognitive risk factors for suicidal ideation. However, they have not been well studied among racial and ethnic minorities. The present study examined the association between these factors (brooding rumination, reflective rumination, hopelessness, and depressive symptoms) and suicidal ideation, among 690 Black, Latino, and biracial college students. Among all groups, hopelessness was positively associated with suicidal ideation. Brooding was negatively associated with suicidal ideation, after adjusting for reflection and hopelessness, although only at low levels of depressive symptoms. Black race/ethnicity and Latino race/ethnicity, compared with biracial race/ethnicity, each separately interacted with reflection to predict lower levels of suicidal ideation at moderate to high levels of reflection. Furthermore, Latino race/ethnicity, compared with biracial race/ethnicity, interacted with both reflection and depressive symptoms, such that reflection was negatively associated with suicidal ideation among Latino individuals reporting depressive symptoms above the 39th percentile. Biracial race/ethnicity, compared with monoracial race/ethnicity, also interacted with reflection and depressive symptoms, with reflection associated with greater amounts of suicidal ideation at depressive symptom levels above the 39th percentile. Our findings suggest reflective rumination differentially affects racial and ethnic groups and should be considered in conjunction with depressive symptoms among Latino and biracial individuals in suicide risk assessment and treatment.
PMCID: PMC4828660  PMID: 25111544
race; ethnicity; rumination; depression; suicidal ideation
6.  Sexual Orientation and Risk Factors for Suicidal Ideation and Suicide Attempts: a Multi-centre Cross-Sectional Study in Three Asian Cities 
Journal of Epidemiology  2015;25(2):155-161.
Despite robust empirical and theoretical evidence for higher rates of suicide among lesbian, gay, and bisexual (LGB) youths, little is known about the relationship between suicide and sexual orientation among Asian youths. This study examined differences in prevalence of suicidal ideation and suicide attempts between LGB and heterosexual youths in the cities of Hanoi, Shanghai, and Taipei, China.
The data are from a community-based multi-centre cross-sectional study conducted from 2006 to 2007, with a sample of 17 016 youths aged 15–24 years from Hanoi, Shanghai, and Taipei. Chi-square test and logistic regression were used to evaluate correlates of suicidal ideation and suicide attempts.
The overall prevalence of suicidal ideation and suicide attempts in the preceding 12 months in LGB youths were both higher than in heterosexual youth (12.8% vs. 8.1% and 4.0% vs. 2.4%, respectively). Stratified by city, the prevalence of suicidal ideation was lowest in Hanoi (2.2%), followed by Shanghai (8.0%) and Taipei (17.0%). Similar trends were observed in the prevalence of suicide attempts, which was lowest in Hanoi (0.3%), followed by Shanghai (1.2%) and Taipei (2.5%). Of note, however, multivariate logistic regression results revealed that LGB youth were at a higher risk for suicidal ideation than heterosexual youth only in Taipei (odds ratio 1.65).
Suicidality is common among Asian youth, with higher prevalence observed in urbanized cities. LGB youths are at greater risk of suicidal ideation than their heterosexual counterparts in Taipei than in the other two examined cities.
PMCID: PMC4310877  PMID: 25446798
suicide; China; Vietnam; Taiwan; sexual orientation; youth
7.  Gay-Straight Alliances, Social Justice Involvement, and School Victimization of Lesbian, Gay, Bisexual, and Queer Youth: Implications for School Well-Being and Plans to Vote 
Youth & society  2013;45(4):500-522.
Few studies have investigated school-based, positive development for lesbian, gay, bisexual, and queer (LGBQ) youth, despite knowledge of their heightened negative school experiences compared to heterosexual youth (e.g., school victimization). This study examines associations among participation in Gay-Straight Alliance (GSA)–related social justice activities, GSA presence, and GSA membership with victimization based on sexual orientation and school-based well-being (i.e., school safety, school belongingness, grade point average [GPA]) and future plans to vote. Using data from the Preventing School Harassment Study, a survey of 230 LGBQ students in 7th through 12th grades, the study finds that participation in GSA-related social justice activities and the presence of a GSA are positively associated with school belongingness and GPA. GSA membership is also positively associated with school belongingness. However, moderation analyses suggest that the positive benefits of GSA-related social justice involvement and the presence of a GSA dissipate at high levels of school victimization. Implications for schools are discussed.
PMCID: PMC4516126  PMID: 26224893
social justice; gay—straight alliances; victimization; academic achievement; LGBT issues
8.  Associations between impulsivity, aggression, and suicide in Chinese college students 
BMC Public Health  2014;14:551.
Although there are accumulating data regarding the epidemiology of suicide in China, there are meager data on suicidal ideation and attempts among college students. Interestingly, elevated impulsivity is thought to facilitate the transition from suicidal thoughts to suicidal behavior. Therefore, the objective of this research was to identify the associations between suicide and the personality factors of impulsivity and aggression.
This study’s sampling method employed stratified random cluster sampling. A multi-stage stratified sampling procedure was used to select participants (n = 5,245). We conducted structured interviews regarding a range of socio-demographic characteristics and suicidal morbidity. The Patient Health Questionnaire depression module (PHQ-9) was used to acquire the information about thoughts of being better off dead or hurting themselves in some ways during the past two weeks. The impulsivity symptoms in this study were assessed with the BIS-11-CH (i.e., the Chinese version of the BIS-11), and the Aggressive symptoms were assessed with the BAQ. The statistical package for social science (SPSS) v.13.0 program (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Socio-demographic variables such as ethnic and gender were compared between groups, through the use of χ2 tests. The nonparametric test (k Independent Sample test, Kruskal-Wallis H) was performed to determine differences between the personality factors of impulsivity and aggression and suicide.
In total, 9.1% (n = 479) of the 5,245 students reported they have ever thought about committing suicide; and 1% (n = 51) reported a history of attempted suicide (attempters). The analyses detected significant differences in scores on cognitive impulsivity (p < 0.01), when comparing individuals who only had suicidal ideation and individuals who had attempted suicide. Moreover, significant differences were found between ideators only and attempters on scores of self-oriented attack (p < .001).
Suicidal ideation is prevalent among Chinese university students. Students with high aggression scores were more susceptible to committing suicide. Scores on self-oriented attack and cognitive impulsivity may be important factors for differentially predicting suicide ideation and suicide attempts.
PMCID: PMC4082288  PMID: 24894449
Suicidal ideation; Suicidal attempters; Impulsivity; Aggression; University students; Correlations
9.  Belief system, meaningfulness, and psychopathology associated with suicidality among Chinese college students: a cross-sectional survey 
BMC Public Health  2012;12:668.
Research suggests that Chinese religious believers are more likely to commit suicide than those identifying as non-religious among rural young adults, contrary to findings in Western countries. However, one cannot conclude that religiosity is associated with elevated suicide risk without examining the effect of political and religious beliefs in a generally atheist country like China where political belief plays a dominant role in the belief system of young adults. The present study investigated the effects of political and religious belief on suicidality with meaningfulness and psychopathology as potential mediators in a large representative sample of Chinese college students.
A cross-sectional survey was conducted among 1390 first-year college students randomly sampled from 10 colleges and universities in mainland China.
A total of 1168 respondents (84.0%) provided complete data on all variables. Lifetime prevalence of suicidal ideation, plan, and attempt were 45.1%, 6.8%, and 1.9% respectively, with one-year suicidal ideation showing at 19.3%. Female gender was associated with elevated risk of suicidality. Political belief but not religious belief was associated with decreased suicide risk. A significant interactive effect of political belief and religious belief was found, indicating that for political believers, being religious was associated with decreased suicide risk; for non-political believers, being religious was associated with increased suicide risk. Multi-group structural equation modeling showed that meaningfulness completely mediated and psychopathology partially mediated the effect of belief system on suicidality. Gender differences were found in pathways of political belief by religious beliefs to suicidality and political belief to psychopathology. The coefficients were significant for males but not for females.
In less religious societies, political belief may serve as a means of integration as does religious affiliation in religious societies. Males were more likely to benefit from the protective effect of a belief system on suicidality than females.
PMCID: PMC3491076  PMID: 22898096
Suicidality; Religion; Political belief; Meaningfulness; Psychopathology; China
10.  Prevalence and predictors of persistent suicide ideation, plans, and attempts during college 
Journal of affective disorders  2010;127(1-3):287-294.
Suicide is the second-leading cause of death among college students in the US and is preventable. Approximately 1,100 college students die by suicide each year. This study examined the prevalence and predictors of one-time and persistent suicide ideation, plans, and attempts reported during college.
Data were gathered prospectively over four years. Face-to-face interviews were conducted with 1,253 first-year college students at one large mid-Atlantic university. Risk factors were measured in Year 1.
An estimated 12%wt of individuals experienced suicide ideation at some point during college, and of those individuals, 25% had more than one episode of ideation (persistent ideation; 2.6%wt of the overall sample). Ten individuals had a plan or attempt during college (0.9%wt of the sample). Risk factors for persistent suicide ideation included low social support, childhood or adolescent exposure to domestic violence, maternal depression, and high self-reported depressive symptoms. Persistent ideators differed from one-time ideators only by higher levels of depression (p=.027). Persistent ideators were no more likely than one-time ideators to have made a suicide plan or attempt during college (8% vs. 9%, respectively).
Although the sample size is large, only a small percentage of participants had persistent ideation, suicide plans or attempts during college.
These results have implications for programs aimed at identifying college students at risk for suicide. The accurate identification of college students at-risk for suicide is an important step toward suicide prevention.
PMCID: PMC2924459  PMID: 20471691
College students; Depression; Family psychopathology; Social support; Suicidal behavior; Suicide ideation
11.  The Association of Multiple Identities with Self-directed Violence and Depression among Transgender Individuals 
Transgender individuals have a high prevalence of self-directed violence; however, there is scant literature focusing on their unique experiences. This study examined the differences in self-harm, suicidal ideation, suicide attempt, and depression based on racial/ethnic identity and sexual orientation among transgender individuals. Data were gathered from the Fall 2008 and Spring 2009 National College Health Assessment. Across racial/ethnic identities, greater proportions of transgender students endorse self-directed violence than their cisgender peers. Among transgender individuals, sexual minorities were more likely to report suicidal ideation than their heterosexual peers, and racial/ethnic minorities had higher odds of attempting suicide than non-Hispanic white individuals.
PMCID: PMC5087282  PMID: 26916366
12.  Association between Non-Suicidal Self-Injuries and Suicide Attempts in Chinese Adolescents and College Students: A Cross-Section Study 
PLoS ONE  2011;6(4):e17977.
This study examined the association between non-suicidal self-injury (NSSI) and suicide attempts among Chinese adolescents and college students.
A total sample of 2013 Chinese students were randomly selected from five schools in Wuhan, China, including 1101 boys and 912 girls with the age ranging between 10 and 24 years. NSSI, suicidal ideation, suicide attempts and depressive symptoms were measured by self-rated questionnaires. Self-reported suicide attempts were regressed on suicidal ideation and NSSI, controlling for participants' depressive symptoms, and demographic characteristics.
The self-reported prevalence rates of NSSI, suicidal ideation, suicide attempts were 15.5%, 8.8%, and 3.5%, respectively. Logistic regression analyses indicated that NSSI was significantly associated with self-reported suicide attempts. Analyses examining the conditional association of NSSI and suicidal ideation with self-reported suicide attempts revealed that NSSI was significantly associated with greater risk of suicide attempts in those not reporting suicidal ideation than those reporting suicidal ideation in the past year.
These findings highlight the importance of NSSI as a potentially independent risk factor for suicide attempts among Chinese/Han adolescents and college students.
PMCID: PMC3072963  PMID: 21494656
13.  Suicide ideation, plans, and attempts among general practice patients with chronic health conditions in Puerto Rico 
Little is known about suicidal ideation among general practice patients in Puerto Rico. In this study we examined the rates, severity, and correlates of suicidal ideation, plans, and attempts among general practice patients with chronic illnesses. This is important in targeting appropriate interventions and management approaches to minimize and prevent suicide.
We screened patients with chronic physical conditions at general practices. Suicidal ideation was assessed with the suicidality module of the Mini International Neuropsychiatric Interview. Major depression was assessed with the Patient Health Questionnaire depression module. The relationship between sociodemographic factors, depression and suicidal ideation was examined with multiple logistic regression analysis. Among the subgroup that acknowledged suicidal ideation, we used multinomial logistic regression analysis to estimate simultaneously the multivariate associations of depression and sociodemographic factors with suicidality risk levels.
Of the 2068 patients screened, 15.4% acknowledged recent suicidal ideation. Among this group, 8.6% reported passive ideation, 3.7% active ideation without a plan, and 3.1% active ideation with a plan or attempt. According to multivariate logistic regression, suicidal ideation was higher among patients with moderately severe depression and severe depression than for those with milder symptoms. Patients aged 64 years or younger were over one and a half times more likely to acknowledge suicidal ideation than those aged 65 years and older. Compared with patients having a college degree, those with lower education had a twofold higher risk of suicidal ideation. Multinomial logistic regression analysis indicated that severe depression was associated with a higher likelihood of having a suicide plan or attempt.
The findings of this study suggest that public health strategies focusing on the systematic identification of patients with increased depression severity and the implementation of evidence-based depression treatments are relevant for minimizing and preventing suicidal behavior among general practice patients with chronic health conditions.
PMCID: PMC3068880  PMID: 21475631
suicidal ideation; chronic illnesses; depression; Puerto Rican
14.  How do Sexual Identity, and Coming Out Affect Stress, Depression, and Suicidal Ideation and Attempts Among Men Who Have Sex With Men in South Korea? 
This study investigated the status of sexual identity, perceived stigma, stress, depression, and suicidal ideation and attempts. It also examined how sexual identity and “coming out” affect stress, depression, and suicidal ideation and attempts.
Suicidal ideation, psychological health status, and health-related behaviors were assessed using the Internet to maximize the confidentiality of the participants, men who have sex with men (MSM). The data were collected from a total of 873 MSM aged between 19 years and 59 years in 2014.
Only 20.9% of the MSM had come out (18.0% voluntarily and 2.9% by others). The prevalences of perceived stress and depression among MSM were 46.7% and 42.7%, respectively, compared with 20.1% and 7.4% among general men. Approximately 32% of the MSM reported any suicidal ideation, and 3.3% had attempted suicide in the past year. The likelihood of suicidal ideation was significantly associated with being age 30–39 years [odds ratio (OR) = 1.8], high school or less (OR = 1.6), having been outed (OR = 5.2), feeling stressed (OR = 1.8), and feeling depressed (OR = 12.4) after sociodemographic factors and other perceptions were controlled for.
The present study provides evidence that MSM are at an elevated risk for suicidal ideation and attempts with high stress and depression. Some risk factors were specific to being gay or bisexual in a hostile environment.
PMCID: PMC5079205  PMID: 27812485
coming out; depression; sexual identity; stigma; stress; suicidal ideation and attempts
15.  Prevalence and familial predictors of suicidal behaviour among adolescents in Lithuania: a cross-sectional survey 2014 
BMC Public Health  2016;16:554.
In the past decades Lithuania has been experiencing a very high suicide rate among young people and there are scarce data on the role of the family in shaping these people suicidal behaviour. This study investigated the prevalence of suicidal ideation and attempts, as well as their association with a range of familial factors in a representative sample of Lithuanian adolescents.
Study subjects (N = 3572) were adolescents aged 13- and 15-years from the schools in Lithuania who were surveyed in Spring 2014 according to the methodology of the cross-national Health Behaviour in School-aged Children (HBSC). A standard HBSC international questionnaire was translated into Lithuanian and used anonymously to obtain information about suicidal behaviour (stopped doing activities, considered suicide, planned suicide, and suicide attempts) and family life (family structure, quality of communication in family, parental monitoring and bonding, parenting style, family time, etc.). Logistic regression was used to assess association between suicidal behaviours and familial variables.
Forty three percents of surveyed adolescents reported presence of emotions that stopped doing activities during the last 12 months, 23.8 % seriously considered attempting suicide, 13.7 % made a suicide plan, 13.2 % attempted suicide, and 4.1 % needed treatment because of suicide attempt in the previous year. Adolescents from non-intact families reported more suicidal ideation (OR ranged from 1.32 to 1.35, P < 0.05) and more suicide attempts (OR = 1.70, 95 % CI 1.38-2.09, P < 0.001). Among adolescents from intact families, some manisfestations of suicidal behaviour were significantly associated with low satisfaction in family relationships, low father’s and mother’s emotional support, low mother’s monitoring, low school-related parental support, authoritarian-repressive father’s parenting style and permissive-neglectful mother’s parenting style, but rare family time together and rare electronic media communication with parents were inversely associated with suicidal behaviour. The boys, 15-year-olds and adolescents who indicated often activities together with their families were more likely than their counterparts to report suicide attempts treated by a doctor or nurse.
The young people of Lithuania are at particular risk for suicides. A non-intact family structure and weak family functioning are significant predictors of suicidal ideation and attempts among adolescents of Lithuania. It is essential to consider family life practices in planning intervention programs for prevention of suicides among adolescents.
PMCID: PMC4942925  PMID: 27405357
Suicide; Suicidal behaviour; Adolescents; Family; Parent–child relationships; Parenting
16.  Correlation between Family Environment and Suicidal Ideation in University Students in China 
Background: This study investigated the association between suicidal ideation and family environment. The sample included 5183 Chinese university students. A number of studies on suicidal ideation have focused on individuals rather than families. This paper reviews the general principles of suicidal ideation and the consequences resulting from the family environment. Methods: This study used six different colleges as the dataset, which included 2645 males and 2538 females. Students were questioned with respect to social demographics and suicidal ideation factors. The data were analyzed with factor and logistic analyses to determine the association between suicidal ideation and poor family environment. Results: The prevalence of suicidal ideation was 9.2% (476/5183). Most participants with suicidal ideation had significant similarities: they had poor family structures and relationships, their parents had unstable work, and their parents used improper parenting styles. Female students were more likely to have suicidal thoughts than male students. Conclusions: This study shows that suicidal ideation is a public health issue among Chinese university students and demonstrates the importance of considering the family environment when examining university students’ suicidal ideation. Understanding family-related suicidal ideation risk factors can help to predict and prevent suicides among university students.
PMCID: PMC4344674  PMID: 25633031
China; university students; family environment; suicidal ideation
17.  Suicide related ideation and behavior among Canadian gay and bisexual men: a syndemic analysis 
BMC Public Health  2015;15:597.
While several studies have demonstrated that gay and bisexual men are at increased risk of suicide less attention has been given to the processes that generate the inherent inequity with the mainstream population. This study tested whether syndemic theory can explain the excess suicide burden in a sample of Canadian gay and bisexual men. Syndemic theory accounts for co-occurring and mutually reinforcing epidemics suffered by vulnerable groups due to the effects of social marginalization.
This study used data from Sex Now 2011, a cross-sectional survey of Canadian gay and bisexual men (n = 8382). The analysis measured the extent to which anti-gay marginalization and several psychosocial health problems are associated with suicide related ideation and attempts. Since psychosocial health problems were hypothesized to have an additive effect on suicide related ideation and attempts, the analysis calculated the effect of accumulated psychosocial health problems on suicide behavior.
Suicide ideation and attempts were positively associated with each individual marginalization indicator (verbal violence, physical violence, bullying, sexual violence and work discrimination) and psychosocial health problems (smoking, party drugs, depression, anxiety, STIs, HIV risk and HIV). Furthermore, prevalence of suicide ideation and attempts increased with each added psychosocial health problem. Those who reported 3 or more had 6.90 (5.47–8.70) times the odds of experiencing suicide ideation and 16.29 (9.82–27.02) times the odds of a suicide attempt compared to those with no psychosocial health problems.
This investigation suggests that syndemics is a useful theory for studying suicide behavior among gay and bisexual men. Moreover, the findings highlight a need to address gay and bisexual men’s health problems holistically and the urgent need to reduce this population’s experience with marginalization and violence.
PMCID: PMC4489209  PMID: 26136235
Gay men; Bisexual men; Suicide; Syndemic; Homophobia; Violence; Canada
18.  Using the Patient Health Questionnaire (PHQ-9) and the Edinburgh Postnatal Depression Scale (EPDS) to Assess Suicidal Ideation among Pregnant Women in Lima, Peru 
Archives of women's mental health  2014;18(6):783-792.
We sought to examine the concordance of two suicidal ideation items from the Patient Health Questionnaire-9 (PHQ-9) and the Edinburgh Postnatal Depression Scale (EPDS), to evaluate the prevalence of suicidal ideation among pregnant women, and to assess the co-occurrence of suicidal ideation with antepartum depressive symptoms. A cross-sectional study was conducted among 1,517 pregnant women attending prenatal care clinics in Lima, Peru. Item 9 of the PHQ-9 assesses suicidal ideation over the last 14 days while item 10 of the EPDS assesses suicidal ideation in the past 7 days. The two suicidal ideation items have a high concordance rate (84.2%) but a moderate agreement (the Cohen's kappa = 0.42). Based on the PHQ-9 and the EPDS, 15.8% and 8.8% of participants screened positive for suicidal ideation, respectively. Assessed by the PHQ-9, 51% of participants with suicidal ideation had probable depression. In prenatal care clinics, screening for suicidal ideation is needed for women with and without depressive symptoms. Future studies are needed to identify additional predictors of antepartum suicidality, determine the appropriate duration of reporting period for suicidal ideation screening, and assess the percentage of individuals with positive responses to the two suicidal ideation items at high risk of planning and attempting suicide.
PMCID: PMC4635023  PMID: 25369907
Suicidal ideation; antepartum depressive symptoms; PHQ-9; EPDS
19.  Suicidal ideation among Métis adult men and women – associated risk and protective factors: findings from a nationally representative survey 
International Journal of Circumpolar Health  2012;71:10.3402/ijch.v71i0.18829.
To determine the prevalence of suicidal ideation among Métis men and women (20–59 years) and identify its associated risk and protective factors using data from the nationally representative Aboriginal Peoples Survey (2006).
Study design
Secondary analysis of previously collected data from a nationally representative cross-sectional survey.
Across Canada, lifetime suicidal ideation was reported by an estimated 13.3% (or an estimated 34,517 individuals) of the total population of 20-to-59-year-old Métis. Of those who ideated, 46.2% reported a lifetime suicide attempt and 6.0% indicated that they had attempted suicide in the previous 12 months. Prevalence of suicidal ideation was higher among Métis men than in men who did not report Aboriginal identity in examined jurisdictions. Métis women were more likely to report suicidal ideation compared with Métis men (14.9% vs. 11.5%, respectively). Métis women and men had some common associated risk and protective factors such as major depressive episode, history of self-injury, perceived Aboriginal-specific community issues, divorced status, high mobility, self-rated thriving health, high self-esteem and positive coping ability. However, in Métis women alone, heavy frequent drinking, history of foster care experience and lower levels of social support were significant associated risk factors of suicidal ideation. Furthermore, a significant interaction was observed between social support and major depressive episode. Among Métis men, history of ever smoking was the sole unique associated risk factor.
The higher prevalence of suicidal ideation among Métis women compared with Métis men and the observed gender differences in associations with some associated risk and protective factors suggest the need for gender-responsive programming to address suicidal ideation.
PMCID: PMC3417687  PMID: 22901287
Métis; Aboriginal; Indigenous; suicidal thoughts; suicidality; suicidal behavior
20.  School-Based Strategies to Reduce Suicidal Ideation, Suicide Attempts, and Discrimination among Sexual Minority and Heterosexual Adolescents in Western Canada 
This study explored the relationships between the existence of and length of time since implementation of school-based Gay-Straight Alliances (GSAs) and explicit anti-homophobic bullying policies in secondary schools across British Columbia, Canada, with experiences of anti-gay discrimination, suicidal ideation and attempts among lesbian, gay, bisexual (LGB), mostly heterosexual, and exclusively heterosexual students. Analyses of the province-wide random cluster-stratified 2008 B.C. Adolescent Health Survey (n =21,70 8) compared students in schools with GSAs or policies implemented at least 3 years, and less than 3 years, with those in schools without GSAs or anti-homophobia policies, using multinomial logistic regression, separately by gender. LGB students had lower odds of past year discrimination, suicidal thoughts and attempts, mostly when policies and GSAs had been in place for 3+ years; policies had a less consistent effect than GSAs. Heterosexual boys, but not girls, also had lower odds of suicidal ideation and attempts in schools with longer-established anti-homophobic bullying policies and GSAs. Given consistently higher documented risk for suicidal ideation and attempts among LGB and mostly heterosexual adolescents, prevention efforts should be a priority, and school-level interventions, such as GSAs, may be an effective approach to reducing this risk, while also offering prevention benefits for heterosexual boys.
PMCID: PMC4716826  PMID: 26793284 CAMSID: cams5381
sexual orientation; suicidal ideation; suicide attempt; gay-straight alliance; adolescent; school policy; school-based surveys; homophobia
21.  Suicide and related health risk behaviours among school learners in South Africa: results from the 2002 and 2008 national youth risk behaviour surveys 
BMC Public Health  2013;13:926.
Attempted and completed suicide constitute a major public health problem among young people world-wide, including South Africa (SA). Suicide attempt and completed suicide increase during the adolescent period. One in 5 adolescents considers attempting suicide, but statistics are frequently unreliable.
Data for this study were derived from the 2002 and 2008 South African Youth Risk Behaviour Surveys (YRBS). The study population comprised grades 8, 9, 10 and 11 students in governmental schools in the nine provinces of SA (N = 10,699 in 2002 and 10,270 in 2008). Key outcome measures were suicide ideation and suicide attempts.
Of the total sample, 18% of the students in 2002 and 19% in 2008 reported to have seriously considered and/or made a plan to commit suicide during the past six months (Suicide ideation), whereas 18.5% of students in 2002 and 21.8% in 2008 reported that they had attempted suicide at least 1 time during the past six months. On both suicide measures girls have higher prevalence scores than boys, and older school learners score higher than younger learners. In addition, 32% of the learners reported feelings of sadness or hopelessness. These feelings contributed significantly to the explanation of suicide ideation and suicide attempt next to being the victim or actor in violent acts and illegal substance use.
The prevalence of suicide ideation and suicide attempts among South African adolescents is high and seems to be influenced by a wide spectrum of factors at the demographic, psychological and behavioural level. Hence, more research is needed to determine the behavioural and psychological determinants of suicide among youngsters in order to develop comprehensive intervention strategies for suicide prevention and care.
PMCID: PMC3851142  PMID: 24093214
22.  Risk indicators of suicide ideation among on-reserve First Nations youth 
Paediatrics & Child Health  2013;18(1):15-20.
Despite the known disparity in suicide rates in Canada, there is limited information on the independent risk indicators of suicide ideation among First Nations youth living on reserve.
To determine the prevalence and adjusted risk indicators for suicide ideation among on-reserve First Nations youth.
Saskatoon Tribal Council (Saskatchewan) First Nations students enrolled in grades 5 through 8 who were living on reserve were asked to complete a health survey using validated questionnaires. In total, 75.3% of the students completed the survey. The study was led by the Saskatoon Tribal Council with assistance from three departments at the University of Saskatchewan (Saskatoon, Saskatchewan).
Among on-reserve First Nations youth, 23% experienced suicide ideation within the past 12 months. In comparison, 8.5% of Saskatoon urban youth and 19% of Saskatoon urban Aboriginal youth within the same grades experienced suicide ideation. Wanting to leave home (OR 13.91 [95% CI 3.05 to 63.42]), having depressed mood (OR 2.98 [95% CI 1.16 to 7.67]) and not feeling loved (OR 3.85 [95% CI 1.49 to 9.93]) were independently associated with suicide ideation among on-reserve youth. None of the children with a father who was professionally employed reported suicide ideation.
Understanding the independent risk indicators associated with suicide ideation among First Nations youth living on reserve will hopefully aid in appropriate interventions.
PMCID: PMC3680266  PMID: 24381486
Minority groups; Risk factors; Suicide; Youth
23.  Suicidal Ideation, Depression, and Aggression Among Students of Three Universities of Isfahan, Iran in 2008 
Objective: University students’ mental health affects not only their educational achievements, but also their professional future. The authors assessed the prevalence of suicidal ideation, depression, and aggression among students of three major universities in Isfahan, Iran.
Methods: In 2008, 470 students were entered into the study using a convenience sampling method. The three measurement tools applied were Aggression Questionnaire (AGQ), Beck Depression Inventor (BDI), and Beck Scale for Suicide Ideation (BSSI).
Results: Suicidal ideation was present in 7.58% of the students, depression in 28.04%, and aggression in 30.11% of them. The ratio of depression to suicidal ideation was approximately 4:1. No significant difference in the mean scores of aggression, depression, and suicidal ideation was observed between the three universities. No significant relationships were found between mean scores of aggression, depression, and suicidal ideation with age and gender. There was no meaningful relationship between the mean scores of aggression and marriage status, but the mean scores of depression (P = 0.01) and suicidal ideation (P = 0.0001) were significantly lower in the married students compared to the single ones. Aggression was significantly associated with depression and suicidal ideation (P = 0.0001).
Conclusion: The frequency of suicidal ideation, aggression, and depression was less in our studied college students than in previous non–Iranian studies. The decreasing trend in reported frequency of mild depression during previous years is a noticeable finding. Yet, the findings seek more preventing programs among college students.
PMCID: PMC3939947  PMID: 24644469
Aggression; College Students; Depression; Suicidal Ideation
24.  Prevalence of Suicidal Ideation in Chinese College Students: A Meta-Analysis 
PLoS ONE  2014;9(10):e104368.
About 1 million people worldwide commit suicide each year, and college students with suicidal ideation are at high risk of suicide. The prevalence of suicidal ideation in college students has been estimated extensively, but quantitative syntheses of overall prevalence are scarce, especially in China. Accurate estimates of prevalence are important for making public policy. In this paper, we aimed to determine the prevalence of suicidal ideation in Chinese college students.
Objective and Methods
Databases including PubMed, Web of Knowledge, Chinese Web of Knowledge, Wangfang (Chinese database) and Weipu (Chinese database) were systematically reviewed to identify articles published between 2004 to July 2013, in either English or Chinese, reporting prevalence estimates of suicidal ideation among Chinese college students. The strategy also included a secondary search of reference lists of records retrieved from databases. Then the prevalence estimates were summarized using a random effects model. The effects of moderator variables on the prevalence estimates were assessed using a meta-regression model.
A total of 41 studies involving 160339 college students were identified, and the prevalence ranged from 1.24% to 26.00%. The overall pooled prevalence of suicidal ideation among Chinese college students was 10.72% (95%CI: 8.41% to 13.28%). We noted substantial heterogeneity in prevalence estimates. Subgroup analyses showed that prevalence of suicidal ideation in females is higher than in males.
The prevalence of suicidal ideation in Chinese college students is relatively high, although the suicide rate is lower compared with the entire society, suggesting the need for local surveys to inform the development of health services for college students.
PMCID: PMC4186746  PMID: 25285890
25.  Time to Emergence of Severe Suicidal Ideation among Psychiatric Patients as a Function of Suicide Attempt History 
Comprehensive psychiatry  2007;49(1):6-12.
Little is known about the emergence of suicidal ideation among psychiatric inpatients with histories of no, single, or multiple suicide attempts. We investigated differences in time to reemergence of severe suicidal ideation among psychiatric patients as a function of their suicide attempt histories.
One hundred seventeen individuals meeting criteria for a major depressive disorder who were recently discharged from a psychiatric hospital and participating in a larger study of treatments for depression were included in the current study. Suicidal ideation, depressive symptoms, hopelessness, and depressogenic cognitions were assessed at baseline, and suicidal ideation was assessed at 3, 6, 12, and 18 month follow up, as well as inpatient readmission if applicable. Time to the reemergence of severe suicidal ideation was analyzed using survival analysis.
Twenty-two percent of our sample reported the occurrence of severe suicidal ideation over an 18-month period. Severe suicidal ideation emerged earlier among patients who had a history of prior suicide attempts than those who did not, but single and multiple suicide attempters did not differ significantly in time to severe suicidal ideation. Suicide attempt history remained a significant predictor of time to severe suicidal ideation when statistically controlling for hopelessness, depressive symptoms, depressogenic cognitions, and suicidal ideation at admission and initial treatment group assignment, especially between single and non-attempters.
Although nearly a quarter of participants endorsed severe, clinically significant suicidal ideation within 18 months of discharge, those with suicide attempt histories reported the occurrence of severe suicidal ideation significantly earlier than those without suicide attempt histories.
PMCID: PMC4120022  PMID: 18063035

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