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1.  Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior: Findings from the WHO World Mental Health Surveys 
PLoS Medicine  2009;6(8):e1000123.
Using data from over 100,000 individuals in 21 countries participating in the WHO World Mental Health Surveys, Matthew Nock and colleagues investigate which mental health disorders increase the odds of experiencing suicidal thoughts and actual suicide attempts, and how these relationships differ across developed and developing countries.
Background
Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts.
Methods and Findings
Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9–8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5–5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies.
Conclusions
This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.
Please see later in the article for Editors' Summary
Editors' Summary
Background
Suicide is a leading cause of death worldwide. Every 40 seconds, someone somewhere commits suicide. Over a year, this adds up to about 1 million self-inflicted deaths. In the USA, for example, where suicide is the 11th leading cause of death, more than 30,000 people commit suicide every year. The figures for nonfatal suicidal behavior (suicidal thoughts or ideation, suicide planning, and suicide attempts) are even more shocking. Globally, suicide attempts, for example, are estimated to be 20 times as frequent as completed suicides. Risk factors for nonfatal suicidal behaviors and for suicide include depression and other mental disorders, alcohol or drug abuse, stressful life events, a family history of suicide, and having a friend or relative commit suicide. Importantly, nonfatal suicidal behaviors are powerful predictors of subsequent suicide deaths so individuals who talk about killing themselves must always be taken seriously and given as much help as possible by friends, relatives, and mental-health professionals.
Why Was This Study Done?
Experts believe that it might be possible to find ways to decrease suicide rates by answering three questions. First, which individual mental disorders are predictive of nonfatal suicidal behaviors? Although previous studies have reported that virtually all mental disorders are associated with an increased risk of suicidal behaviors, people often have two or more mental disorders (“comorbidity”), so many of these associations may reflect the effects of only a few disorders. Second, do some mental disorders predict suicidal ideation whereas others predict who will act on these thoughts? Finally, are the associations between mental disorders and suicidal behavior similar in developed countries (where most studies have been done) and in developing countries? By answering these questions, it should be possible to improve the screening, clinical risk assessment, and treatment of suicide around the world. Thus, in this study, the researchers undertake a cross-national analysis of the associations among mental disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV]) and nonfatal suicidal behaviors.
What Did the Researchers Do and Find?
The researchers collected and analyzed data on the lifetime presence and age-of-onset of mental disorders and of nonfatal suicidal behaviors in structured interviews with nearly 110,000 participants from 21 countries (part of the World Health Organization's World Mental Health Survey Initiative). The lifetime presence of each of the 16 disorders considered (mood disorders such as depression; anxiety disorders such as post-traumatic stress disorder [PTSD]; impulse-control disorders such as attention deficit/hyperactivity disorder; and substance misuse) predicted first suicide attempts in both developed and developing countries. However, the increased risk of a suicide attempt associated with each disorder varied. So, for example, in developed countries, after controlling for comorbid mental disorders, major depression increased the risk of a suicide attempt 3-fold but drug abuse/dependency increased the risk only 2-fold. Similarly, although the strongest predictors of suicide attempts in developed countries were mood disorders, in developing countries the strongest predictors were impulse-control disorders, substance misuse disorders, and PTSD. Other analyses indicate that mental disorders were generally more predictive of the onset of suicidal thoughts than of suicide plans and attempts, but that anxiety and poor impulse-control disorders were the strongest predictors of suicide attempts in both developed and developing countries.
What Do These Findings Mean?
Although this study has several limitations—for example, it relies on retrospective self-reports by study participants—its findings nevertheless provide a more detailed understanding of the associations between mental disorders and subsequent suicidal behaviors than previously available. In particular, its findings reveal that a wide range of individual mental disorders increase the chances of an individual thinking about suicide in both developed and developing countries and provide new information about the mental disorders that predict which people with suicidal ideas will act on such thoughts. However, the findings also show that only half of people who have seriously considered killing themselves have a mental disorder. Thus although future suicide prevention efforts should include a focus on screening and treating mental disorders, ways must also be found to identify the many people without mental disorders who are at risk of suicidal behaviors.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000123.
The US National Institute of Mental Health provides information about suicide in the US: statistics and prevention
The UK National Health Service provides information about suicide, including statistics about suicide in the UK and links to other resources
The World Health Organization provides global statistics about suicide and information on suicide prevention
MedlinePlus provides links to further information and advice about suicide and about mental health (in English and Spanish)
Further details about the World Mental Health Survey Initiative and about DSM-IV are available
doi:10.1371/journal.pmed.1000123
PMCID: PMC2717212  PMID: 19668361
2.  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
3.  Gender Differences in Emotional Risk for Self- and Other-Directed Violence among Externalizing Adults 
OBJECTIVE
Women and men generally differ in how frequently they engage in other-and self-directed physical violence and may show distinct emotional risk factors for engagement in these high-impact behaviors. To inform this area, we investigated gender differences in the relationship of emotional tendencies (i.e., anger, hostility, and anhedonic depression) that may represent risk for other-directed (i.e., physical fighting, attacking others unprovoked) and self-directed violence (i.e., self-injury, suicide attempts).
METHOD
The ethnically-diverse sample consisted of 372 adults (252 men and 120 women ages 18–55) with a history of criminal convictions. Facets of emotional risk assessed with the Aggression Questionnaire (Buss & Warren, 2000) and Mood and Anxiety Symptom Questionnaire (Watson et al., 1995) were entered simultaneously as explanatory variables in regression analyses to investigate their unique contributions to other- and self-directed physical violence in men and women.
RESULTS
Analyses revealed anhedonic depressive tendencies negatively predicted other-directed violence and positively predicted self-directed violence in both men and women, consistent with a model of depression in which aggression is turned inwards (Henriksson et al., 1993). Gender differences, however, emerged for the differential contributions of anger and hostility to other-and self-directed violence. Specifically, trait anger (i.e., difficulty controlling one’s temper) was associated with other-directed violence selectively in men, whereas trait hostility (i.e., suspiciousness and alienation) was associated with self- and other-directed violence among women.
CONCLUSIONS
The divergent findings for trait anger and hostility underscore the need to examine gender-specific risk factors for physical violence to avoid excluding potentially useful clinical features of these mental health outcomes.
doi:10.1037/a0022197
PMCID: PMC3368376  PMID: 21261437
Anger; hostility; anhedonic depression; violence; gender; suicide; aggression
4.  Associations between impulsivity, aggression, and suicide in Chinese college students 
BMC Public Health  2014;14:551.
Background
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.
Methods
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.
Results
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).
Conclusions
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.
doi:10.1186/1471-2458-14-551
PMCID: PMC4082288  PMID: 24894449
Suicidal ideation; Suicidal attempters; Impulsivity; Aggression; University students; Correlations
5.  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
6.  Parental Psychopathology and the Risk of Suicidal Behavior in their Offspring: Results from the World Mental Health Surveys 
Molecular psychiatry  2010;16(12):1221-1233.
Prior research suggests that parental psychopathology predicts suicidal behavior among offspring; however, the more fine-grained associations between specific parental disorders and distinct stages of the pathway to suicide are not well-understood. We set out to test the hypothesis that parental disorders associated with negative mood would predict offspring suicide ideation, whereas disorders characterized by impulsive-aggression (e,g., antisocial personality) and anxiety/agitation (e.g., panic disorder) would predict which offspring act on their suicide ideation and make a suicide attempt. Data were collected during face-to-face interviews conducted on nationally representative samples (N=55,299; age 18+) from 21 countries around the world. We tested the associations between a range of parental disorders and the onset and persistence over time (i.e., time-since-most-recent-episode controlling for age-of-onset and time-since-onset) of subsequent suicidal behavior (suicide ideation, plans, and attempts) among offspring. Analyses tested bivariate and multivariate associations between each parental disorder and distinct forms of suicidal behavior. Results revealed that each parental disorder examined increased the risk of suicide ideation among offspring, parental generalized anxiety and depression emerged as the only predictors of the onset and persistence (respectively) of suicide plans among offspring with ideation, whereas parental anti-social personality and anxiety disorders emerged as the only predictors of the onset and persistence of suicide attempts among ideators. A dose-response relation between parental disorders and respondent risk of suicide ideation and attempt also was found. Parental death by suicide was a particularly strong predictor of persistence of suicide attempts among offspring. These associations remained significant after controlling for comorbidity of parental disorders and for the presence of mental disorders among offspring. These findings should inform future explorations of the mechanisms of inter-generational transmission of suicidal behavior.
doi:10.1038/mp.2010.111
PMCID: PMC3142278  PMID: 21079606
suicide; parent and family history; intergenerational transmission
7.  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
8.  Allergy: A Risk Factor for Suicide? 
Opinion statement
The rates of depression, anxiety, and sleep disturbance (suicide risk factors) are greater in patients with allergic rhinitis than in the general population. The rate of allergy is also greater in patients with depression. Preliminary data suggest that patients with a history of allergy may have an increased rate of suicide. Clinicians should actively inquire to diagnose allergy in patients with depression and depression in patients with allergy.
Spring peaks of suicide are highly replicated, but their origin is poorly understood. Preliminary epidemiologic data suggest that seasonal spring peaks in aeroallergens are associated with seasonal spring peaks in suicide. Our research in Brown Norway rats demonstrates that sensitization and exposure to aeroallergens induces anxiety-like and aggressive behaviors as well as allergy-related helper T-cell type 2 (Th2) cytokine gene expression in the prefrontal cortex. Thus, it is possible that sensitization and exposure to aeroallergens, which peak in spring, may be conducive to seasonal exacerbation of suicide risk factors such as anxiety, depression, hostility/ aggression, and sleep disturbance. Connecting allergy with suicide and suicide risk factors adds to previous neurologic literature connecting allergy with migraines and seizure disorders.
Our recent report of Th2 (allergy-mediating) cytokine expression in the orbito-frontal cortex of suicide victims should lead to future studies to test the hypothesis that mediators of allergic inflammation in the nasal cavities may result in Th2 cytokine expression in the brain, influencing affect and behavioral modulation.
Certain medications used to treat allergy can exacerbate suicide risk factors, potentially worsening suicide risk and even triggering suicide. Systemic (but not topical) corticosteroids have been associated with manic and depressive episodes and mixed mood states. Recently, the US Food and Drug Administration started investigating the possibility that montelukast may trigger suicide. Although this association requires further exploration and confirmation, clinicians should err on the side of caution, inquiring about past suicide attempts; hopelessness; reasons for living; and suicidal ideation, intent, or plan; and referring the patient to a mental health professional for evaluation if appropriate.
PMCID: PMC2592251  PMID: 18782509
9.  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
10.  Suicidal tendencies and attitude towards freedom to choose suicide among Lithuanian schoolchildren: results from three cross-sectional studies in 1994, 1998, and 2002 
BMC Public Health  2005;5:83.
Background
Suicidal behaviour is increasingly becoming a phenomenon associated with young people and an important public health issue in Lithuania. However, there are very few studies evaluating impact of young peoples' attitudes towards suicide to their suicidal behaviour. A better understanding of the relations among the variables associated with suicidal ideation and threats in the normal population of adolescents may eventually result in a better understanding of the more serious forms of adolescent suicidal behaviour. The aim of the present study was to evaluate prevalence of suicidal tendencies among Lithuanian schoolchildren and to estimate its association with an attitude towards suicide in 1994 – 2002.
Methods
Three country representative samples of schoolchildren, aged 11, 13 and 15, were surveyed in 1994 (n = 5428), 1998 (n = 4513), and 2002 (n = 5645) anonymously in conformity with the methodology of the World Health Organization Cross – National study on Health Behaviour in School-aged Children (HBSC).
Results
About one third of respondents reported about suicidal ideation, plans or attempts to commit suicide. In the study period of eight years, the percentage of adolescents who reported sometime suicidal ideation decreased but the percentage of adolescents who declared serious suicidal behaviour remained on the same high level (8.1%, 9.8% and 8.4% correspondingly in 1994, 1998 and 2002). Moreover, the number of suicidal attempts changed from 1.0% in 1994 to 1.8% in the year 1998 and to 1,7% in the year 2002. The schoolchildren's attitude towards suicide became more agreeable: 36.6%, 41.9% and 62.5% of respondents, correspondingly in 1994, 1998 and 2002, answered that they agree with a person's freedom to make a choice between life and suicide. A multiple logistic regression analysis with low level of suicidality and high level of suicidality versus non suicidal behaviour as dependent variables for gender, age, year of the survey and attitude towards freedom to choose suicide as independent variables approved a significant association between studied covariates over the entire study period.
Conclusion
Suicidal tendencies are quite frequent among Lithuanian adolescents. An increasing number of schoolchildren are expressing an agreeable attitude towards suicide. The approving attitude towards suicide among adolescents correlates with suicidal ideation and behaviour.
doi:10.1186/1471-2458-5-83
PMCID: PMC1201149  PMID: 16092973
11.  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
12.  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.
13.  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
14.  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
15.  Suicidal behaviors in depressed adolescents: role of perceived relationships in the family 
Context
Suicide is the second leading cause of death in adolescents and young adults in Europe. Reducing suicides is therefore a key public health target. Previous studies have shown associations between suicidal behaviors, depression and family factors.
Objective
To assess the role of family factors in depression and suicidality in a large community-based sample of adolescents and to explore specific contributions (e.g. mother vs. father; conflict vs. no conflict; separation vs. no separation) taking into account other risk factors.
Methods
A cross-sectional sample of adolescents aged 17 years was recruited in 2008. 36,757 French adolescents (18,593 girls and 18,164 boys) completed a questionnaire including socio-demographic characteristics, drug use, family variables, suicidal ideations and attempts. Current depression was assessed with the Adolescent Depression Rating Scale (ADRS). Adolescents were divided into 4 groups according to suicide risk severity (grade 1 = depressed without suicidal ideation and without suicide attempts, grade 2 = depressed with suicidal ideations and grade 3 = depressed with suicide attempts; grade 0 = control group). Multivariate regressions were applied to assess the Odds Ratio of potential risk factors comparing grade 1, 2 or 3 risk with grade 0.
Results
7.5% of adolescents (10.4% among girls vs. 4.5% among boys) had ADRS scores compatible with depression; 16.2% reported suicidal ideations in the past 12 months and 8.2% reported lifetime suicide attempts. Repeating a year in school was significantly associated to severity grade of suicide risk (1 and 3), as well as all substance use, tobacco use (severity grades 2 and 3) and marijuana use (severity grade 3), for girls and boys. After adjustment, negative relationships with either or both parents, and parents living together but with a negative relationship were significantly associated with suicide risk and/or depression in both genders (all risk grades), and Odds Ratios increased according to risk severity grade.
Conclusion
Family discord and negative relationship with parents were associated with an increased suicide risk in depressed adolescents. So it appears essential to take intrafamilial relationships into account in depressed adolescents to prevent suicidal behaviours.
doi:10.1186/1753-2000-7-8
PMCID: PMC3655930  PMID: 23497551
Suicide; Depression; Adolescent; Community survey
16.  Sensation Seeking as Risk Factor for Suicidal Ideation and Suicide Attempts in Adolescence 
Journal of affective disorders  2012;143(1-3):214-222.
Background
High sensation seeking in adolescence is associated with engagement in risk-taking behaviors, especially substance use. Although depressed adolescents are prone to increased risk-taking, and suicidal behavior can be considered within the spectrum of risk-taking behaviors, the relationships between sensation seeking, depression, and suicidal behavior have not been explored.
Methods
A self-report questionnaire assessing sensation seeking, depression, substance use problems, and suicidal ideation and suicide attempts was completed by 9th- through 12th-grade students (n=2189) in six New York State high-schools from 2002 through 2004. Logistic regression analyses were conducted to examine main and interaction effects between sensation seeking and the four clinical variables.
Results
High sensation seeking was positively associated with depressive symptoms and substance use problems. The main effects of sensation seeking on suicidal ideation and suicide attempts remained significant after controlling for depression and substance use. The association between sensation seeking and suicide attempts was moderated by substance use problems.
Limitations
The schools were suburban and predominantly white, limiting the generalizability of the results. Other mental disorders with potential implications for sensation seeking and for suicidal behavior, such as bipolar disorders, were not assessed.
Conclusions
The finding that sensation seeking makes an independent contribution to the risk of suicidal ideation and attempts is consistent with findings in literature on novelty seeking and impulsivity. The associations between sensation seeking, depressive symptoms and suicidal behavior may be compatible with the presence of an underlying temperamental dysregulation. Screening for sensation seeking may contribute to the reduction of adolescent suicide risk.
doi:10.1016/j.jad.2012.05.058
PMCID: PMC3501599  PMID: 22921521
Sensation seeking; Adolescence; Suicidal ideation; Suicide attempts; Depression; Substance use
17.  African-American adolescents’ stress responses after the 9/11/01 terrorist attacks 
The Journal of Adolescent Health  2005;36(3):201-207.
Purpose
To examine the impact of indirect exposure to the 9/11/01 attacks upon physical and emotional stress-related responses in a community sample of African-American (AA) adolescents.
Methods
Three months after the 9/11/01 terrorist attacks, 406 AA adolescents (mean age [SD] of 16.1 ± 1.3 years) from an inner-city high school in Augusta, GA were evaluated with a 12-item 5-point Likert scale measuring loss of psychosocial resources (PRS) such as control, hope, optimism, and perceived support, a 17-item 5-point Likert scale measuring post-traumatic stress symptomatology (PCL), and measures of state and trait anger, anger expression, and hostility. Given the observational nature of the study, statistical differences and correlations were evaluated for effect size before statistical testing (5% minimum variance explained). Bootstrapping was used for testing mean differences and differences between correlations.
Results
PCL scores indicated that approximately 10% of the sample was experiencing probable clinically significant levels of post-traumatic distress (PCL score > 50). The PCL and PRS were moderately correlated with a r = .59. Gender differences for the PCL and PRS were small, accounting for 1% of the total variance. Higher PCL scores were associated with higher state anger (r = .47), as well as measures of anger-out (r = .32) and trait anger (r = .34). Higher PRS scores were associated only with higher state anger (r = .27). Scores on the two 9/11/01-related scales were not statistically associated (i.e., less than 5% of the variance explained) with traits of anger control, anger-in, or hostility.
Conclusions
The majority of students were not overly stressed by indirect exposure to the events of 9/11/01, perhaps owing to the temporal, social, and/or geographical distance from the event. Those who reported greater negative impact appeared to also be experiencing higher levels of current anger and exhibited a characterologic style of higher overt anger expression.
doi:10.1016/j.jadohealth.2004.02.035
PMCID: PMC3286004  PMID: 15737775
Adolescents; Post-traumatic stress; September 11, 2001 attacks; African-American; Anger; Hostility
18.  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
19.  DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF CONSISTENT AND INCONSISTENT LONGITUDINAL REPORTERS OF LIFETIME SUICIDE ATTEMPTS IN ADOLESCENCE THROUGH YOUNG ADULTHOOD 
Depression and anxiety  2013;30(10):997-1004.
Background
Within the context of the recent release of the 2012 National Suicide Prevention Strategy, and as the third leading cause of death for individuals 10- to 24-years-old, suicide prevention is a national priority. A consistently reported and robust risk factor for suicide is a prior suicide attempt; however few studies have investigated the consistency of self-reported lifetime suicide attempts. The goal of this study is to describe the prevalence and characteristics of inconsistent reporting of suicide attempt in a longitudinal cohort of participants annually assessed in 12 waves of data collected from middle school (age 12) to early adulthood (age 22).
Methods
Among this cohort (n = 678), we compared those who consistently, inconsistently, and never reported a suicide attempt according to demographic and clinical variables.
Results
Almost 90% (88.5%) of our sample inconsistently reported a lifetime suicide attempt. Consistent and inconsistent reporters of lifetime suicide attempt did not differ on demographic or clinical variables with the exception of higher rates of lifetime suicidal ideation among consistent reporters (P < .001). Significant clinical differences were evident between inconsistent reporters and nonattempters.
Conclusions
Some level of inconsistent reporting of suicide attempt is inevitable when schools or health care systems systematically screen for suicide risk in adolescents. Inconsistent and consistent reporters of suicide attempt differ on few demographic or clinical variables; further prospective research should investigate the reasons for inconsistent reporting as well as the validity and stability of reporting in predicting future suicidal behavior.
doi:10.1002/da.22135
PMCID: PMC4083681  PMID: 23804209
suicide; attempted; reliability; risk factors; longitudinal studies; research design
20.  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
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.  Parental involvement in the war in Croatia 1991-1995 and suicidality in Croatian male adolescents 
Croatian Medical Journal  2012;53(3):244-253.
Aim
To investigate the association between parental war involvement and different indicators of psychosocial distress in a community sample of early adolescents ten years after the war in Croatia 1991-1995.
Methods
A total of 695 adolescents were screened with a self-report questionnaire assessing parental war involvement, sociodemographic characteristics, and alcohol and drug consumption. Personality traits were assessed with the Junior Eysenck Personality Questionnaire; depressive symptoms with the Children’s Depression Inventory (CDI); and unintentional injuries, physical fighting, and bullying with the World Health Organization survey Health Behavior in School-aged Children. Suicidal ideation was assessed with three dichotomous items. Suicidal attempts were assessed with one dichotomous item.
Results
Out of 348 boys and 347 girls who were included in the analysis, 57.7% had at least one veteran parent. Male children of war veterans had higher rates of unintentional injuries (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.56 to 2.63) and more frequent affirmative responses across the full suicidal spectrum (thoughts about death – OR, 2.1; 95% CI, 1.02 to 4.3; thoughts about suicide – OR, 5; 95% CI, 1.72 to 14.66; suicide attempts – OR, 3.6; 95% CI, 1.03 to 12.67). In boys, thoughts about suicide and unintentional injuries were associated with parental war involvement even after logistic regression. However, girls were less likely to be affected by parental war involvement, and only exhibited signs of psychopathology on the CDI total score.
Conclusion
Parental war involvement was associated with negative psychosocial sequels for male children. This relationship is possibly mediated by some kind of identification or secondary traumatization. Suicidality and unintentional injuries are nonspecific markers for a broad range of psychosocial distresses, which is why the suggested target group for preventive interventions should be veteran parents as vectors of this distress.
doi:10.3325/cmj.2012.53.244
PMCID: PMC3370406  PMID: 22661138
23.  Drugs Associated with More Suicidal Ideations Are also Associated with More Suicide Attempts 
PLoS ONE  2009;4(10):e7312.
Context
In randomized controlled trials (RCTs), some drugs, including CB1 antagonists for obesity treatment, have been shown to cause increased suicidal ideation. A key question is whether drugs that increase or are associated with increased suicidal ideations are also associated with suicidal behavior, or whether drug–induced suicidal ideations are unlinked epiphenomena that do not presage the more troubling and potentially irrevocable outcome of suicidal behavior. This is difficult to determine in RCTs because of the rarity of suicidal attempts and completions.
Objective
To determine whether drugs associated with more suicidal ideations are also associated with more suicide attempts in large spontaneous adverse event (AE) report databases.
Methodology
Generalized linear models with negative binomial distribution were fitted to Food and Drug Administration (FDA) Adverse Event (AE) Reporting System (AERS) data from 2004 to 2008. A total of 1,404,470 AEs from 832 drugs were analyzed as a function of reports of suicidal ideations; other non-suicidal adverse reactions; drug class; proportion of reports from males; and average age of subject for which AE was filed. Drug was treated as the unit of analysis, thus the statistical models effectively had 832 observations.
Main Outcome Measures
Reported suicide attempts and completed suicides per drug.
Results
832 drugs, ranging from abacavir to zopiclone, were evaluated. The 832 drugs, as primary suspect drugs in a given adverse event, accounted for over 99.9% of recorded AERS. Suicidal ideations had a significant positive association with suicide attempts (p<.0001) and had an approximately 131-fold stronger magnitude of association than non-suicidal AERs, after adjusting for drug class, gender, and age.
Conclusions
In AE reports, drugs that are associated with increased suicidal ideations are also associated with increased suicidal attempts or completions. This association suggests that drug-induced suicidal ideations observed in RCTs plausibly represent harbingers that presage the more serious suicide attempts and completions and should be a cause for concern.
doi:10.1371/journal.pone.0007312
PMCID: PMC2749439  PMID: 19798416
24.  Intimate Partner Violence and Incident Depressive Symptoms and Suicide Attempts: A Systematic Review of Longitudinal Studies 
PLoS Medicine  2013;10(5):e1001439.
Karen Devries and colleagues conduct a systematic review of longitudinal studies to evaluate the direction of association between symptoms of depression and intimate partner violence.
Please see later in the article for the Editors' Summary
Background
Depression and suicide are responsible for a substantial burden of disease globally. Evidence suggests that intimate partner violence (IPV) experience is associated with increased risk of depression, but also that people with mental disorders are at increased risk of violence. We aimed to investigate the extent to which IPV experience is associated with incident depression and suicide attempts, and vice versa, in both women and men.
Methods and Findings
We conducted a systematic review and meta-analysis of longitudinal studies published before February 1, 2013. More than 22,000 records from 20 databases were searched for studies examining physical and/or sexual intimate partner or dating violence and symptoms of depression, diagnosed major depressive disorder, dysthymia, mild depression, or suicide attempts. Random effects meta-analyses were used to generate pooled odds ratios (ORs). Sixteen studies with 36,163 participants met our inclusion criteria. All studies included female participants; four studies also included male participants. Few controlled for key potential confounders other than demographics. All but one depression study measured only depressive symptoms. For women, there was clear evidence of an association between IPV and incident depressive symptoms, with 12 of 13 studies showing a positive direction of association and 11 reaching statistical significance; pooled OR from six studies = 1.97 (95% CI 1.56–2.48, I2 = 50.4%, pheterogeneity = 0.073). There was also evidence of an association in the reverse direction between depressive symptoms and incident IPV (pooled OR from four studies = 1.93, 95% CI 1.51–2.48, I2 = 0%, p = 0.481). IPV was also associated with incident suicide attempts. For men, evidence suggested that IPV was associated with incident depressive symptoms, but there was no clear evidence of an association between IPV and suicide attempts or depression and incident IPV.
Conclusions
In women, IPV was associated with incident depressive symptoms, and depressive symptoms with incident IPV. IPV was associated with incident suicide attempts. In men, few studies were conducted, but evidence suggested IPV was associated with incident depressive symptoms. There was no clear evidence of association with suicide attempts.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Depression and suicide are responsible for a substantial proportion of the global disease burden. Depression—an overwhelming feeling of sadness and hopelessness that can last for months or years—affects more than 350 million people worldwide. It is the eleventh leading cause of global disability-adjusted life-years (a measure of overall disease burden), and it affects one in six people at some time during their lives. Globally, about a million people commit suicide every year, usually because they have depression or some other mental illness. Notably, in cross-sectional studies (investigations that look at a population at a single time point), experience of intimate partner violence (IPV, also called domestic violence) is strongly and consistently associated with both depressive disorders and suicide. IPV, like depression and suicide, is extremely common—in multi-country studies, 15%–71% of women report being physically assaulted at some time during their lifetime. IPV is defined as physical, sexual, or psychological harm by a current or former partner or spouse; men as well as women can be the victims of IPV.
Why Was This Study Done?
It may seem obvious to assume that IPV is causally related to subsequent depression and suicidal behavior. However, cross-sectional studies provide no information about causality, and it is possible that depression and/or suicide attempts cause subsequent IPV or that there are common risk factors for IPV, depression, and suicide. For example, individuals with depressive symptoms may be more accepting of partners with characteristics that predispose them to use violence, or early life exposure to violence may predispose individuals to both depression and choosing violent partners. Here, as part of the Global Burden of Disease Study 2010, the researchers investigate the extent to which experience of IPV is associated with subsequent depression and suicide attempts and vice versa in both men and women by undertaking a systematic review and meta-analysis of longitudinal studies that have examined IPV, depression, and suicide attempts. A systematic review uses predefined criteria to identify all the research on a given topic, meta-analysis combines the results of several studies, and longitudinal studies track people over time to investigate associations between specific characteristics and outcomes.
What Did the Researchers Do and Find?
The researchers identified 16 longitudinal studies involving a total of 36,163 participants that met their inclusion criteria. All the studies included women, but only four also included men. All the studies were undertaken in high- and middle-income countries. For women, 11 studies showed a statistically significant association (an association unlikely to have occurred by chance) between IPV and subsequent depressive symptoms. In a meta-analysis of six studies, experience of IPV nearly doubled the risk of women subsequently reporting depressive symptoms. In addition, there was evidence of an association in the reverse direction. In a meta-analysis of four studies, depressive symptoms nearly doubled the risk of women subsequently experiencing IPV. IPV was also associated with subsequent suicide attempts among women. For men, there was some evidence from two studies that IPV was associated with depressive symptoms but no evidence for an association between IPV and subsequent suicide attempt or between depressive symptoms and subsequent IPV.
What Do These Findings Mean?
These findings suggest that women who are exposed to IPV are at increased risk of subsequent depression and that women who are depressed are more likely to be at risk of IPV. They also provide evidence of an association between IPV and subsequent suicide attempt for women. The study provides little evidence for similar relationships among men, but additional studies are needed to confirm this finding. Moreover, the accuracy of these findings is likely to be affected by several limitations of the study. For example, few of the included studies controlled for other factors that might have affected both exposure to IPV and depressive symptoms, and none of the studies considered the effect of emotional violence on depressive symptoms and suicide attempts. Nevertheless, these findings have two important implications. First, they suggest that preventing violence against women has the potential to reduce the global burden of disease related to depression and suicide. Second, they suggest that clinicians should pay attention to past experiences of violence and the risk of future violence when treating women who present with symptoms of depression.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001439.
This study is further discussed in a PLOS Medicine Perspective by Alexander Tsai
The US National Institute of Mental Health provides information on all aspects of depression and of suicide and suicide prevention (in English and Spanish)
The UK National Health Service Choices website provides detailed information about depression, including personal stories about depression, and information on suicide and its prevention; it has a webpage about domestic violence, which includes descriptions of personal experiences
The World Health Organization provides information on depression, on the global burden of suicide and on suicide prevention, and on intimate partner violence (some information in several languages)
MedlinePlus provides links to other resources about depression, suicide, and domestic violence (in English and Spanish)
The charity Healthtalkonline has personal stories about depression and about dealing with suicide
doi:10.1371/journal.pmed.1001439
PMCID: PMC3646718  PMID: 23671407
25.  Association between parental psychopathology and suicidal behavior among adult offspring: results from the cross-sectional South African Stress and Health survey 
BMC Psychiatry  2014;14:65.
Background
Prior studies have demonstrated a link between parental psychopathology and offspring suicidal behavior. However, it remains unclear what aspects of suicidal behavior among adult offspring are predicted by specific parental mental disorders, especially in Africa. This study set out to investigate the association between parental psychopathology and suicidal behavior among their adult offspring in a South African general population sample.
Method
Parental psychopathology and suicidal behavior in offspring were assessed using structured interviews among 4,315 respondents from across South Africa. The WHO CIDI was used to collect data on suicidal behavior, while the Family History Research Diagnostic Criteria Interview was used to assess prior parental psychopathology. Bivariate and multivariate survival models tested the associations between the type and number parental mental disorders (including suicide) and lifetime suicidal behavior in the offspring. Associations between a range of parental disorders and the onset of subsequent suicidal behavior (suicidal ideation, plans, and attempts) among adult offspring were tested.
Results
The presence of parental psychopathology significantly increased the odds of suicidal behavior among their adult offspring. More specifically, parental panic disorder was associated with offspring suicidal ideation, while parental panic disorder, generalized anxiety disorder and suicide were significantly associated with offspring suicide attempts. Among those with suicidal ideation, none of the tested forms of parental psychopathology was associated with having suicide plans or attempts. There was a dose–response relationship between the number of parental disorders and odds of suicidal ideation.
Conclusions
Parental psychopathology increases the odds of suicidal behavior among their adult offspring in the South African context, replicating results found in other regions. Specific parental disorders predicted the onset and persistence of suicidal ideation or attempts in their offspring. Further research into these associations is recommended in order to determine the mechanisms through which parent psychopathology increases the odds of suicidal behavior among offspring.
doi:10.1186/1471-244X-14-65
PMCID: PMC3944470  PMID: 24592882
Suicide; Parental psychopathology; South Africa

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