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1.  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.
Purpose
This study examined the association between non-suicidal self-injury (NSSI) and suicide attempts among Chinese adolescents and college students.
Methods
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.
Results
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.
Conclusions
These findings highlight the importance of NSSI as a potentially independent risk factor for suicide attempts among Chinese/Han adolescents and college students.
doi:10.1371/journal.pone.0017977
PMCID: PMC3072963  PMID: 21494656
2.  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.
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1471-2458-13-926
PMCID: PMC3851142  PMID: 24093214
3.  Self-Harm and Suicidal Behaviors in Hong Kong Adolescents: Prevalence and Psychosocial Correlates 
The Scientific World Journal  2012;2012:932540.
The present paper examined the prevalence and psychosocial correlates of adolescent deliberate self-harm (DSH) and suicidal behavior in a representative sample of 3,328 secondary school students in Hong Kong. With reference to the previous year, 32.7% of the students reported at least one form of DSH, 13.7% of the respondents had suicide thoughts, 4.9% devised specific suicidal plans, and 4.7% had actually attempted suicide. Adolescent girls had significantly higher rates of DSH and suicidal behavior than did adolescent boys. Having remarried parents was related to an increased likelihood of DSH and suicide. While high levels of family functioning, overall positive youth development, and academic and school performance predicted low rates of DSH and suicidal behavior, cognitive and behavioral competencies were unexpectedly found to be positively associated with DSH and suicidal behavior. Theoretical and practical implications of the findings are discussed.
doi:10.1100/2012/932540
PMCID: PMC3322490  PMID: 22566783
4.  HIGH SCHOOL ATHLETIC PARTICIPATION AND ADOLESCENT SUICIDE 
Suicide is the third leading cause of death among US adolescents aged 15–24, with males incurring higher rates of completion than females. This study used hierarchical logistic regression analysis to test whether athletic participation was associated with lower rates of suicidal ideation and behavior among a nationally representative sample of over 16,000 US public and private high school students. Net of the effects of age, race/ethnicity, parental educational attainment, and urbanicity, high school athletic participation was significantly associated with reduced odds of considering suicide among both females and males, and reduced odds of planning a suicide attempt among females only. Though the results point to favorable health outcomes for athletes, athletic participation was also associated with higher rates of injury to male athletes who actually attempted suicide.
doi:10.1177/1012690205052160
PMCID: PMC2563797  PMID: 18846245
adolescence; athletic participation and gender; health; suicide
5.  Risk factors for suicide among Indian adolescents at a boarding school. 
Public Health Reports  1989;104(6):609-614.
Suicide rates among American Indians, especially adolescents, are higher than those for the general population. This paper summarizes the relevant literature on prevalence of, and risk factors for, suicide among American Indian groups, with a strong emphasis on adolescents. Data concerning risk of suicide for a sample of high school students attending an Indian boarding school are presented. Approximately 23 percent of these students had attempted suicide at some time in the past, and 33 percent reported suicidal ideation within the past month. Students at greatest risk for suicide include those who reported having either family or friends who had attempted suicide and those who reported on standardized psychological measures as having experienced greater depressive symptomatology, greater quantity and frequency of alcohol use, or little family support. In a 1988 survey of community-based programs for Indian adolescents, 194 were identified as carrying out significant suicide prevention activities. Forty-one of those programs were school-based; they emphasized early identification of students' mental health problems and reduction of specific risk factors such as substance abuse.
PMCID: PMC1580161  PMID: 2511594
6.  Effects of life satisfaction and psychache on risk for suicidal behaviour: a cross-sectional study based on data from Chinese undergraduates 
BMJ Open  2014;4(3):e004096.
Objectives
To examine predictive power of psychache and life satisfaction on risks for suicidal ideation and suicide attempt among young people.
Design
A cross-sectional study.
Setting
Data were collected from an online survey in Wuhan, China.
Participants
5988 university students from six universities were selected by a stratified cluster sampling method.
Primary and secondary outcome measures
Suicidal ideation and suicide attempt at some point of the students’ lifetime were the outcomes of interest.
Results
Students with suicidal ideation or attempted suicide reported a lower level of life satisfaction and high degree of psychache than counterparts without suicidal ideation or attempt. Regression analyses indicated that life satisfaction and psychache were significantly associated with the risk of suicidal ideation and the risk of suicidal attempt. Though psychache showed a relatively stronger predictive power than life satisfaction, the effect of the two factors remained significant when they were individually adjusted for personal demographic characteristics. However, when the two factors were included in the model simultaneously to adjust for each other, psychache could fully explain the association between life satisfaction and suicidal attempt. Life satisfaction remained to contribute unique variance in the statistical prediction of suicidal ideation.
Conclusions
Psychache and life satisfaction both have a significant predictive power on risk for suicidal behaviour, and life satisfaction could relieve the predictive power of psychache when suicidal behaviour is just starting. Shneidman's theory that psychache is the pre-eminent psychological cause of suicide is perhaps applicable only to a more serious form of suicidal behaviour.
doi:10.1136/bmjopen-2013-004096
PMCID: PMC3963073  PMID: 24657883
Suicide & self-harm < PSYCHIATRY; Public health < INFECTIOUS DISEASES; Health & safety < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
7.  Longitudinal Trajectories and Predictors of Adolescent Suicidal Ideation and Attempts Following Inpatient Hospitalization 
Remarkably little is known regarding the temporal course of adolescent suicidal ideation and behavior, the prediction of suicidal attempts from changes in suicidal ideation, or the prediction of suicidal attempts after accounting for suicidal ideation as a predictor. A sample of 143 adolescents 12–15 years old was assessed during psychiatric inpatient hospitalization and again at 3, 6, 9, 15, and 18 months postdischarge through a series of structured interviews and parent- and adolescent-reported instruments. Symptoms of depression, posttraumatic stress disorder, externalizing psychopathology, hopelessness, and engagement in several forms of self-injurious/suicidal behaviors (i.e., suicide threats/gestures, plans, nonsuicidal self-injury [NSSI]) were assessed. Latent growth curve analyses revealed a period of suicidal ideation remission between baseline and 6 months following discharge, as well as a subtle period of suicidal ideation reemergence between 9 and 18 months postdischarge. Changes in suicidal ideation predicted suicide attempts. After accounting for the effects of suicidal ideation, baseline suicide threats/gestures also predicted future suicide attempts. Higher adolescent-reported depressive symptoms, lower parent-reported externalizing symptoms, and higher frequencies of NSSI predicted weaker suicidal ideation remission slopes. Findings underscore the need for more longitudinal research on the course of adolescent suicidality.
doi:10.1037/0022-006X.76.1.92
PMCID: PMC3703821  PMID: 18229987
suicidal ideation; suicidal attempts; nonsuicidal self injury; adolescence; longitudinal methods
8.  Suicidal Expression among School-Attending Adolescents in a Middle-Income Sub-Saharan Country  
We investigated correlates for suicidal expression among adolescents in the Seychelles. Data on 1,432 students (52% females) were derived from the Global School-based Health Survey. Participants were divided into three groups: those with no suicidal behavior (N = 1,199); those with suicide ideation/SI (N = 89); and those reporting SI with a plan to carry out a suicide attempt/SISP (N = 139), each within a 12-month recall period. Using multinomial logistic regression, we examined the strength of associations with social, behavioral and economic indicators while adjusting for covariates. Sixteen percent of school-attending adolescents reported a suicidal expression (10% with a plan/6.2% without). Those reporting SI were younger (relative risk ratio RRR = 0.81; CI = 0.68–0.96), indicated signs of depression (RRR = 1.69; CI = 1.05–2.72) and loneliness (RRR=3.36; CI =1.93–5.84). Tobacco use (RRR = 2.34; CI = 1.32–4.12) and not having close friends (RRR = 3.32; CI = 1.54–7.15) were significantly associated with SI. Those with SISP were more likely to be female (RRR = 0.47; 0.30–0.74), anxious (RRR = 3.04; CI = 1.89–4.88) and lonely (RRR = 1.74; CI = 1.07–2.84). Having no close friends (RRR = 2.98; 1.56–5.69) and using tobacco (RRR = 2.41; 1.48–3.91) were also strongly associated. Having parents who were understanding was protective (RRR = 0.50; CI = 0.31–0.82). Our results suggest that school health promotion programs may benefit from targeting multiple factors associated with suicidal expression. More research, particularly multilevel designs are needed to identify peer and family influences which may modify associations with suicidality.
doi:10.3390/ijerph9114122
PMCID: PMC3524616  PMID: 23202835
suicidal expression; adolescent; school health; sub-Saharan Africa
9.  Prevalence, correlates and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication – Adolescent Supplement (NCS-A) 
JAMA psychiatry  2013;70(3):10.1001/2013.jamapsychiatry.55.
Context
Although suicide is the third leading cause of death among US adolescents, little is known about the prevalence, correlates, or treatment of its immediate precursors, adolescent suicidal behaviors (i.e., suicide ideation, plans, and attempts).
Objectives
To estimate lifetime prevalence of suicidal behaviors among US adolescents and associations of retrospectively-reported temporally primary DSM-IV disorders with the subsequent onset of suicidal behaviors.
Design
Dual-frame national sample of adolescents from the National Comorbidity Survey-Replication Adolescent Supplement (NCS-A).
Setting
Face-to-face household interviews with adolescents and questionnaires with parents.
Participants
6,483 adolescents (ages 13–18 years) and parents.
Main outcome measures
Lifetime suicide ideation, plans, and attempts.
Results
The estimated lifetime prevalence of suicide ideation, plans, and attempts among NCS-A respondents is 12.1%, 4.0% and 4.1%. The vast majority of adolescents with these behaviors meet lifetime criteria for at least one DSM-IV mental disorder assessed in the survey. Most temporally primary (based on retrospective age-of-onset reports) fear/anger, distress, disruptive behavior, and substance disorders significantly predict elevated odds of subsequent suicidal behaviors in bivariate models. The most consistently significant associations of these disorders are with suicide ideation, although a number of disorders also predict plans and both planned and unplanned attempts among ideators. Most suicidal adolescents (>80%) receive some form of mental health treatment. In most cases (>55%) treatment starts prior to onset of suicidal behaviors but fails to prevent these behaviors from occurring.
Conclusions
Suicidal behaviors are commonly occurring among US adolescents, with rates that approach those of adults. The vast majority of youth with suicidal behaviors have pre-existing mental disorders. The disorders most powerfully predicting ideation, though, are different from those most powerfully predicting conditional transitions from ideation to plans and attempts. These differences suggest that distinct prediction and prevention strategies are needed for ideation, plans among ideators, planned attempts, and unplanned attempts.
doi:10.1001/2013.jamapsychiatry.55
PMCID: PMC3886236  PMID: 23303463
10.  Suicidal Ideation in Adolescence: Examining the Role of Recent Adverse Experiences 
Journal of adolescence  2011;35(1):175-186.
Although there is a well-known link between adverse experiences and suicidal ideation, there has been little study of the effects of recent adverse experiences on suicidal ideation in teenagers. This study examined the association between recent adverse experiences and suicidal ideation in a sample of 740 at-risk 16-year-old youth in the LONGSCAN studies, as well as potential mediators. 8.9% of the youth reported suicidal ideation. Recent adverse experiences, as a class, were associated with suicidal ideation; both recent physical abuse and recent psychological maltreatment were uniquely associated with suicidal ideation. The links between recent adverse experiences and suicidal ideation were significantly mediated by psychological distress. There were also significant main effect associations between both internalizing behavioral problems and low positive achievement expectations and suicidal ideation. Recent adverse experiences are important in understanding suicidal ideation in high risk youth.
doi:10.1016/j.adolescence.2011.03.003
PMCID: PMC3743921  PMID: 21481447
11.  Cluster C Personality Disorders in Major Depressive Episodes: The Relationship Between Hostility and Suicidal Behavior 
There is some evidence for an association between Cluster C Personality Disorders (CCPD) and suicidal behavior. We compared depressed inpatients with and without CCPD in terms of suicidal behavior and associated psychopathology. Cluster A or B personality disorder co-morbidity were exclusion criteria for both groups (cases and controls). Depressed inpatients with “pure” CCPD had higher levels of suicidal ideation but not more previous suicide attempts compared with patients without CCPD. Greater suicidal ideation in depressed patients with CCPD in our study was associated with more hostility. Future studies examining the relationship between suicidal ideation and hostility in CCPD may clarify whether treatment focused on hostility might be of use for decreasing suicidal ideation in depressed patients with CCPD (Spitzer, Williams, Gibbon et al., 1990).
doi:10.1080/13811110600992928
PMCID: PMC3779124  PMID: 17178644
cluster C personality disorders; depression; hostility; suicide
12.  Risk for Suicidal Ideation and Suicide Attempts Associated with Co-occurring Depression and Conduct Disorders in Early Adolescence 
This study investigates the early manifestation of co-occurring depression and conduct disorders as a predictor of heightened risk for later suicidal ideation and behavior in a community sample of 521 adolescents. Self-reported symptoms of depression and conduct disorder were evaluated in early 6th grade. Suicidal thoughts and behaviors were tracked through multiple assessments carried out over the middle school years. Compared to adolescents with depression symptoms only, conduct disorder symptoms only, or low psychopathology, those with co-occurring depression and conduct disorder symptoms had the highest risk for subsequent suicidal ideation, recurrent suicidal behaviors, and suicide attempts.
doi:10.1111/j.1943-278X.2011.00031.x
PMCID: PMC3683657  PMID: 21463356
13.  High school Bullying as a Risk for Later Depression and Suicidality 
This is the first study to examine whether high-school students experiencing frequent bullying behaviors are at risk for later depression and suicidality. 236 students who reported frequent bullying behavior without depression or suicidality during a suicide screening were interviewed four years later to reassess depression, suicidal ideation, attempts, substance problems, and functional impairment and were compared to “at-risk” youth identified during the screen, including 96 youth who also experienced bullying behavior. Youth who only reported frequent bullying behaviors (as bullies, victims or both) did not develop later depression or suicidality and continued to have fewer psychiatric problems than students identified as at-risk for suicide. Students who experienced bullying behaviors and depression or suicidality were more impaired four years later than those who had only reported depression or suicidality. Thus, assessment of bullying behaviors in screening protocols is recommended.
doi:10.1111/j.1943-278X.2011.00046.x
PMCID: PMC3188679  PMID: 21793875
bullying; adolescents; suicide; high school
14.  Prospective predictors of adolescent suicidality: 6-month post-hospitalization follow-up 
Psychological medicine  2012;43(5):983-993.
Background
The aim of this study was to examine prospective predictors of suicide events, defined as suicide attempts or emergency interventions to reduce suicide risk, in 119 adolescents admitted to an in-patient psychiatric unit for suicidal behaviors and followed naturalistically for 6 months.
Method
Structured diagnostic interviews and self-report instruments were administered to adolescent participants and their parent(s) to assess demographic variables, history of suicidal behavior, psychiatric disorders, family environment and personality/temperament.
Results
Baseline variables that significantly predicted time to a suicide event during follow-up were Black race, high suicidal ideation in the past month, post-traumatic stress disorder (PTSD), childhood sexual abuse (CSA), borderline personality disorder (BPD), low scores on positive affectivity, and high scores on aggression. In a multivariate Cox regression analysis, only Black race, CSA, positive affect intensity and high aggression scores remained significant.
Conclusions
Our findings suggest the following for adolescent populations: (1) in a very high-risk population, risk factors for future attempts may be more difficult to ascertain and some established risk factors (e.g. past suicide attempt) may not distinguish as well; and (2) cross-cutting constructs (e.g. affective and behavioral dysregulation) that underlie multiple psychiatric disorders may be stronger predictors of recurrent suicide events than psychiatric diagnoses. Our finding with respect to positive affect intensity is novel and may have practical implications for the assessment and treatment of adolescent suicide attempters.
doi:10.1017/S0033291712001912
PMCID: PMC3663078  PMID: 22932393
Adolescent; aggression; impulsivity; positive affectivity; suicide
15.  Association of Aggression and Non-Suicidal Self Injury: A School-Based Sample of Adolescents 
PLoS ONE  2013;8(10):e78149.
Purpose
Non-suicidal self-injury (NSSI) in adolescent has drawn increasing attention because it is associated with subsequent depression, drug abuse, anxiety disorders, and suicide. In the present study, we aimed to estimate the prevalence of non-suicidal self-injury (NSSI) in a school-based sample of Chinese adolescents and to explore the association between aggression and NSSI.
Methods
This study was part of a nationwide study on aggression among adolescents in urban areas of China. A sample of 2907 school students including 1436 boys and 1471 girls were randomly selected in Guangdong Province, with their age ranging from 10 to 18 years old. NSSI, aggression, emotional management and other factors were measured by self-administrated questionnaire. Multinomial logistic regression was used to estimate the association between aggression and NSSI, after adjustment for participants’ emotional management, and other potential confounding variables.
Results
The one year self-reported prevalence of NSSI was 33.6%. Of them, 21.7% engaged in ‘minor NSSI’, 11.9% in ‘moderate/severe NSSI’. 96.9% of self-injuries engaged in one to five different types of NSSI in the past year. Hostility, verbal and indirect aggression was significantly associated with self-reported NSSI after adjusting for other potential factors both in ‘minor NSSI’ and ‘moderate/severe NSSI’. Hostility, verbal and indirect aggression was significantly associated with greater risk of ‘minor NSSI’ and ‘moderate/severe NSSI’ in those who had poor emotional management ability.
Conclusion
These findings highlight a high prevalence of NSSI and indicate the importance of hostility, verbal and indirect aggression as potentially risk factor for NSSI among Chinese adolescents.
doi:10.1371/journal.pone.0078149
PMCID: PMC3813494  PMID: 24205132
16.  Suicidal Behaviors among Adolescents in Juvenile Detention: Role of Adverse Life Experiences 
PLoS ONE  2014;9(2):e89408.
Purpose
The purpose of this study was to assess the influence of multiple adverse life experiences (sexual abuse, homelessness, running away, and substance abuse in the family) on suicide ideation and suicide attempt among adolescents at an urban juvenile detention facility in the United States.
Materials and Methods
The study sample included a total of 3,156 adolescents processed at a juvenile detention facility in an urban area in Ohio between 2003 and 2007. The participants, interacting anonymously with a voice enabled computer, self-administered a questionnaire with 100 items related to health risk behaviors.
Results
Overall 19.0% reported ever having thought about suicide (suicide ideation) and 11.9% reported ever having attempted suicide (suicide attempt). In the multivariable logistic regression analysis those reporting sexual abuse (Odds Ratio = 2.75; 95% confidence interval  = 2.08–3.63) and homelessness (1.51; 1.17–1.94) were associated with increased odds of suicide ideation, while sexual abuse (3.01; 2.22–4.08), homelessness (1.49; 1.12–1.98), and running away from home (1.38; 1.06–1.81) were associated with increased odds of a suicide attempt. Those experiencing all four adverse events were 7.81 times more likely (2.41–25.37) to report having ever attempted suicide than those who experienced none of the adverse events.
Conclusions
Considering the high prevalence of adverse life experiences and their association with suicidal behaviors in detained adolescents, these factors should not only be included in the suicide screening tools at the intake and during detention, but should also be used for the intervention programming for suicide prevention.
doi:10.1371/journal.pone.0089408
PMCID: PMC3933541  PMID: 24586756
17.  The association between partner and non-partner aggression and suicidal ideation in patients seeking substance use disorder treatment 
Addictive behaviors  2008;34(2):180-186.
Objective
The present study was designed to examine the relationship between prior partner and non-partner aggression and suicidal ideation in patients seeking drug and alcohol treatment.
Method
Patients entering drug and alcohol treatment (n = 488) were screened for prior partner and non-partner aggression as well as recent suicidal thoughts. We examined the association between aggression and suicidal ideation in bivariate and multivariate models.
Results
Within the past two weeks, 33% (159/488) of the sample reported suicidal ideation. In bivariate analyses, neither psychological nor physical aggression towards a non-partner was related to suicidal ideation. Partner psychological aggression was related to suicidal ideation in bivariate but not multivariate analyses. Physical aggression towards a partner was consistently related to higher rates of suicidal ideation even after controlling for other known risk factors (OR = 1.8; CI = 1.1 - 2.7). Mediational analyses indicate that this relationship was no longer significant after accounting for current negative affect.
Conclusion
Suicidal ideation is common in patients seeking drug and alcohol treatment and particularly likely in those who report prior aggression towards a partner.
doi:10.1016/j.addbeh.2008.10.004
PMCID: PMC2615474  PMID: 18977093
Suicide; alcohol; violence; depression; treatment
18.  Prevalence and predictors of persistent suicide ideation, plans, and attempts during college 
Journal of affective disorders  2010;127(1-3):287-294.
Background
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.
Methods
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.
Results
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).
Limitations
Although the sample size is large, only a small percentage of participants had persistent ideation, suicide plans or attempts during college.
Conclusion
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.
doi:10.1016/j.jad.2010.04.017
PMCID: PMC2924459  PMID: 20471691
College students; Depression; Family psychopathology; Social support; Suicidal behavior; Suicide ideation
19.  Suicidality as a Function of Impulsivity, Callous/Unemotional Traits, and Depressive Symptoms in Youth 
Journal of Abnormal Psychology  2011;120(2):400-413.
Suicidality represents one of the most important areas of risk for adolescents, with both internalizing (e.g., depression, anxiety) and externalizing/antisocial (e.g., substance use, conduct) disorders conferring risk for suicidal ideation and attempts (e.g., Bridge et al., 2006). However, no study has attended to gender differences in relationships between suicidality and different facets of psychopathic tendencies in youth. Further, very little research has focused on disentangling the multiple manifestations of suicide risk in the same study, including behaviors (suicide attempts with intent to die, self- injurious behavior) and general suicide risk marked by suicidal ideation/plans. To better understand these relationships, we recruited 184 adolescents from the community and those in treatment. As predicted, psychopathic traits and depressive symptoms in youth showed differential associations with components of suicidality. Specifically, impulsive traits uniquely contributed to suicide attempts and self- injurious behaviors, above the influence of depression. Indeed, once psychopathic tendencies were entered in the model, depressive symptoms only explained general suicide risk marked by ideation/plans but not behaviors. Further, callous/unemotional traits conferred protection from suicide attempts selectively in girls. These findings have important implications for developing integrative models that incorporate differential relationships between 1) depressed mood and 2) personality risk factors (i.e., impulsivity and callous-unemotional traits) for suicidality in youth.
doi:10.1037/a0021805
PMCID: PMC3367560  PMID: 21280931
Suicide risk; psychopathic tendencies; psychopathy; impulsivity; depression; callous/unemotional; gender; adolescence; youth; internalizing; externalizing
20.  Suicidal Behaviour and Related Risk Factors among School-Aged Youth in the Republic of Benin 
PLoS ONE  2014;9(2):e88233.
Introduction
Research on factors associated with suicidal ideation and suicide attempts has been conducted largely in developed countries. Research on West African countries in particular is lacking.
Methods
Data were obtained from the Global School-based Health Survey conducted in Benin in 2009. This was a cross-sectional study of three grades, spanning Junior and Senior High, which sampled a total of 2,690 adolescents. Data on the occurrence of demographic, psycho-social and socio-environmental risk factors were tested using multinomial logistic regression for their association with suicidal ideation and suicide attempts.
Results
The survey indicated that 23.2% had thought about suicide and 28.3% had made a suicide attempt in the previous year. Anxiety, loneliness, being bullied, alcohol misuse, illicit drug use, and lack of parental support were independently related to the ideation outcomes, suicidal ideation without planning and suicidal ideation with planning. Multinomial regression analysis, using one suicide attempt and multiple suicide attempts as outcomes, revealed that female sex, anxiety, loneliness, being physically attacked, and illicit drug use were associated these outcomes.
Discussion
The prevalence of suicide attempts reported in the survey is relatively high. It is possible that there are cultural factors that could explain this finding. Our research indicates that many factors are related to the occurrence of suicidal ideation and suicide attempts among youth in Benin. Illicit drug use and violence in particular are associated with a high rate of suicide attempts in Benin. Measures to address these issues may reduce the risk of self-inflicted violence.
doi:10.1371/journal.pone.0088233
PMCID: PMC3914941  PMID: 24505443
21.  Impulsivity, Substance Abuse, and Family/Friends History of Suicide Attempts in University Students With and Without Suicidal Ideation 
Objective: Impulsivity appears to play an important role in suicidal behavior. The aim of this cross-sectional study was to compare the impulsivity, substance abuse, and family/friends history of suicide attempt between suicide-ideated and non suicide-ideated university students.
Methods: The research population consisted of all the students of the University of Isfahan in the academic year of 2009-2010. Three hundred and forty students (136 boys and 204 girls) were selected randomly through cluster sampling, of whom 53 participants were suicide-ideated and the rest were non suicide-ideated. The instruments used in this study were the 11th version of Barratt Impulsivity Scale, Suicide Ideation Questionnaire, and the demographic questionnaire. Descriptive statistics and multivariate analysis of variance were used to examine hypothesis.
Results: There was a significant difference between suicide ideated and non-suicide ideated subjects in impulsivity (F=3.83, p< 0.001). Accordingly, significant differences were observed between two groups in attentional (F=8.12, p< 0.005), motor (F=7.67, p< 0.006), and non-planning (F=4.60, p< 0.033) impulsiveness. The results showed a higher incidence of substance abuse, and family/friends suicide attempt among suicide-ideated compared with non suicide-ideated students.
Conclusion: A higher level of impulsivity is probably related to various indices of suicidal behavior. Substance abuse is probably associated with suicidal behavior and this association may involve an interaction with impulsivity. This study provides an initial evidence of familial linkages of suicide ideation and suggests that the loss of an important person in life would be an important predictor of suicide ideation in university students.
PMCID: PMC3939968  PMID: 24644453
Impulsivity; Substance abuse; Suicide ideation; Family
22.  Longitudinal associations between community violence exposure and suicidality 
Purpose
To examine longitudinal associations between community violence exposure and suicide ideation and attempt, and whether depressive symptoms and aggressive behavior are intervening variables in this association.
Methods
Participants were 473 urban and predominantly African American adolescents who completed measures of community violence exposure, depressive symptoms, and suicide ideation and attempt in grades 6, 7, and 8; teachers reported about adolescents’ aggressive behaviors in grades 6, 7, and 8. Path analysis was used to examine direct and indirect associations between community violence exposure in grade 6 and suicide ideation and attempt in grade 8. Depressive symptoms and aggressive behavior were examined as part of an indirect path from grade 6 community violence exposure to later suicide ideation and attempt.
Results
Results revealed an indirect association between community violence exposure and later suicide ideation for males and females; community violence exposure in grade 6 was associated with depressive symptoms in grade 7, which in turn were positively associated with suicide ideation in grade 8. For males, community violence exposure in grade 6 was associated with increases in aggressive behavior in grade 7, which in turn were associated with suicide attempts in grade 8.
Conclusions
Findings suggest indirect pathways between community violence exposure and later suicide ideation and attempt for male and female adolescents. Results highlight the necessity for reducing youth community violence exposure and enhancing strategies for managing the effects of community violence exposure in order to reduce risk for adolescent suicide.
doi:10.1016/j.jadohealth.2008.02.015
PMCID: PMC2605628  PMID: 18809136
adolescents; African American; community violence; suicide
23.  Psychiatric Disorders, Comorbidity, and Suicidality in Mexico 
Journal of affective disorders  2009;124(1-2):98-107.
Background
Prior studies have reported that psychiatric disorders are among the strongest predictors of suicidal behavior (i.e., suicide ideation, plans, and attempts). However, surprisingly little is known about the independent associations between each disorder and each suicidal behavior due to a failure to account for comorbidity.
Methods
This study used data from a representative sample of 5,782 respondents participating in the Mexican National Comorbidity Survey (2001–2002) to examine the unique associations between psychiatric disorders and suicidality.
Results
A prior psychiatric disorder was present in 48.8% of those with a suicide ideation and in 65.2% of those with an attempt. Discrete-time survival models adjusting for comorbidity revealed that conduct disorder and alcohol abuse/dependence were the strongest predictors of a subsequent suicide attempt. Most disorders predicted suicidal ideation but few predicted the transition from ideation to a suicide plan or attempt.
Limitations
M-NCS is a household survey that excluded homeless and institutionalized people, andthe diagnostic instrument used did not include an assessment of all DSM-IV disorders which would increase the comorbidity discussed here.
Conclusions
These results reveal a complex pattern of associations in which diverse psychiatric disorders impact different parts of the pathway to suicide attempts. These findings will help inform clinical and public health efforts aimed at suicide prevention in Mexico and other developing countries.
doi:10.1016/j.jad.2009.10.022
PMCID: PMC2875312  PMID: 19926141
suicide; suicide attempt; risk factors; epidemiology; survey; psychiatric disorder
24.  Adolescent and caregiver perception of family functioning: relation to suicide ideation and attempts 
Psychiatry research  2012;200(2-3):400-403.
This study assessed the relationship between perceived family functioning and two indicators of suicidality in an adolescent sample. A total of 103 adolescents psychiatrically hospitalized for suicidal ideation and/or behavior completed a battery of self-report questionnaires assessing family functioning, negative affectivity, suicidal ideation in the past week assessed by Beck’s Scale for Suicide Ideation (BSS; Beck et al., 1979), and past suicide attempts. Participants’ primary caregivers also completed a questionnaire on family functioning. A paired samples t-test evaluated overall discrepancy between adolescent- and caregiver-reported family functioning. Linear and logistic regression models were used to evaluate the simple associations between perceived family functioning and suicidal indicators (BSS and previous attempt status), as well as the associations between perceived family functioning and suicidal indicators after controlling for negative affect. Results indicated that adolescents’ ratings of family functioning were significantly worse than caregivers’ ratings, and positively associated with BSS scores and a history of suicide attempt. When negative affect was controlled for, adolescent-reported family functioning was significantly associated with BSS, but only trended toward significance with attempt status. Findings suggest that adolescents’ perceptions of family functioning may be a key contributing factor to suicidal ideation in adolescents with psychiatric disorders.
doi:10.1016/j.psychres.2012.07.051
PMCID: PMC3513592  PMID: 22925373
suicide; family functioning; negative affect; adolescence
25.  Suicidal Expression in Adolescents in Nicaragua in Relation to Youth Self-Report (YSR) Syndromes and Exposure to Suicide 
Background:
Suicide and suicidal expressions among young people represent a major public health problem worldwide. Most studies are from high-income countries, and it remains unclear whether prevalence and risk factors show a similar pattern in other settings. This study aims to assess the prevalence of suicidal expressions and serious suicidal expressions (ideation, plans and attempts) among adolescents in Nicaragua, in relation to previously reported risk factors, such as exposure to suicide in significant others (parents, siblings, partners or friends) and mental health problems.
Methods:
368 adolescents aged 15-18 years were randomly selected from public secondary schools in León, Nicaragua. Data was collected using Attitude Towards Suicide (ATTS) and Youth Self-Report questionnaires (YSR). Bivariate and multivariate analyses were conducted.
Results:
Suicide ideation prevalence in the past year was 22.6%, suicide plans 10.3%, and suicide attempts 6.5%. Girls were significantly more likely to report suicidal ideation. Multivariate analyses showed that anxious/depressed, somatic complaints and exposure to suicidal behavior in significant others were significantly associated with own serious suicidal expressions.
Conclusions:
The prevalence of serious suicidal expressions among young people in Nicaragua is within the range reported from Western high-income countries. An attempted or completed suicide in someone close, is associated with own suicidal expressions even in the absence of increased mental distress. Furthermore, somatic complaints should alert health care professionals of the possibility of increased suicide risk.
doi:10.2174/1745017901107010089
PMCID: PMC3089377  PMID: 21559237
Suicidal expressions; youth self report; nicaragua; school based.

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