Relationships between suicide risk, traumatic experiences, and substance use among juvenile detainees.

Youth suicide ideation in juvenile justice settings is a phenomenon with multiple determinants. This article examines relationships among determinants of suicidal ideation utilizing various screening instruments. Consecutive youth admitted to detention in Connecticut (N = 757) completed the Massachusetts Youth Screening Instrument 2 (MAYSI-2), the Suicidal Ideation Questionnaire (SIQ), measures of substance use, and risk and protective factors for violence during intake screening. In bivariate and multivariate analyses (controlling for demographic and MAYSI-2 sub-scale scores), relationships were found between the Traumatic Experiences and Alcohol and Drug Use subscales of the MAYSI-2 and the SIQ. The potential impact of traumatic stress and substance use symptoms in understanding and detecting youths who are at risk for suicide is discussed.     

The risk of adolescent suicide across patterns of drug use: a nationally representative study of high school students in the United States from 1999 to 2009

Objective

Substance use is associated with suicidal ideation, planning and attempts among adolescents, but it is unclear how this association varies across different types and number of substances. This study examined the association between patterns of substance use and suicidality among a nationally representative sample of high school students in the United States during the last decade.

Method

Data from the 2001 to 2009 Youth Risk Behavior Survey including 73,183 high school students were analyzed. Logistic regression analyses examined the association between lifetime use of ten common substances of abuse (alcohol, cocaine, ecstasy, hallucinogens, heroin, inhalants, marijuana, methamphetamines, steroids, and tobacco) and four measures of suicidality over the last year (suicidal ideation, suicide plan, suicide attempt, and severe suicide attempt requiring medical attention), controlling for potential confounders (socio-demographic variables, interpersonal violence, sexual intercourse, and symptoms of depression and eating disorder).

Results

Among the ten substances, univariate analysis demonstrates that adolescents reporting a history of heroin use have the strongest association with suicidal ideation, suicide plan, suicide attempts and severe suicide attempts in the last year (odds ratio = 5.0, 5.9, 12.0, and 23.6 compared to non-users), followed by users of methamphetamines (OR = 4.3–13.1) and steroids (OR = 3.7–11.8). Cocaine, ecstasy, hallucinogens and inhalants had a moderate association with suicidality (OR = 3.1–10.8). Users of marijuana, alcohol and tobacco also had an increased odds ratio of suicidality (OR = 1.9–5.2). The association between each of ten substances and the four measures of suicidality remained significant with multivariate analysis controlling for multiple confounders (p < 0.05), except for the association between alcohol use and severe suicide attempts. The seven illicit substances had a stronger association with severe suicide attempts as compared to all other confounding risk factors except depression. The number of substances used had a graded relationship to suicidality.

Conclusions

Substance abuse is a strong risk factor for suicidal thoughts and behaviors among American high school students, with the strength of this relationship dramatically increasing with particular illicit drugs and a higher number of substances. The findings reinforce the importance of routine screening for substance abuse in the assessment of adolescent suicide risk.     

Predictors of Suicidal Behaviors in Canadian Adolescents with No Recent History of Depression

We examined risk factors for suicidal behaviors (i.e., suicidal ideation and suicide attempts) in the absence of depression during adolescence. Using 6,788 adolescents from the National Longitudinal Survey of Children and Youth (NLSCY), we identified participants with “no recent history of depression.” We then tested the effects of risk factors at age 14–15 on suicidal behaviors at age 16–17. Absence of recent depression history negatively predicted both suicidal ideation and suicide attempt. However, among those with no history of depression, substance use and the presence of a chronic illness both increased the risk of suicidal behaviors. Suicidal behavior in adolescents in the absence of depression history may be explained by factors such as substance use and chronic illness.     

Substance Use Disorders and Poverty as Prospective Predictors of Adult First-Time Suicide Ideation or Attempt in the United States

This study examined whether substance use disorders (SUD) and poverty predicted first-time suicide ideation or attempt in United States national data. Respondents without prior histories of suicide ideation or attempt at Wave 1 of the NESARC (N?=?31,568) were analyzed to determine the main and interactive effects of SUD and poverty on first-time suicide ideation or attempt by Wave 2, 3 years later. Adjusted for controls, poverty (AOR?=?1.35, CI?=?1.05–1.73) and drug use disorders (AOR?=?2.10, CI?=?1.07–4.14) independently increased risk for first-time suicide ideation or attempt at Wave 2. SUD and poverty did not interact to differentially increase risk for first-time suicide ideation or attempt, prior to or after adjustment for controls. This study reinforces the importance of SUD and poverty in the risk for first-time suicide ideation or attempt. Public health efforts should target messages to drug users and the impoverished that highlight their increased risk for first-time suicide.     

Screening for emergent risk and service needs among incarcerated youth: comparing MAYSI-2 and Voice DISC-IV

OBJECTIVE: To examine associations between the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2) and Diagnostic Interview Schedule for Children-Present State Voice Version (DISC-IV) and the extent to which they overlap in identifying youths with mental health concerns. METHOD: Among 325 New Jersey and South Carolina correctional youths, associations were examined using receiver operating characteristic analyses and logistic regression (binomial and multinomial). RESULTS: MAYSI-2 subscales generally mapped best onto homotypic DISC-IV disorders; however, many subscales mapped almost as well onto heterotypic disorders. Alcohol/Drug Use and Suicide Ideation, respectively, identified youths reporting substance disorder and recent attempt; other subscales did not identify parallel DISC-IV disorders as well. CONCLUSIONS: MAYSI-2 identifies some DISC-IV disorders better than others. Lack of overlap may result from MAYSI-2's combining diagnostic constructs into single subscales. Substantial percentages of disordered youths were not identified by corresponding subscales. In systems with multiple avenues of referral, the MAYSI-2 is a useful intake screen, but its utility as the sole means for identifying diagnoses for treatment purposes is limited. The authors differentiate between screening for emergent risk and service needs, recommending best practices for a comprehensive approach to mental health assessment among justice youth.     

Clinical utility and policy implications of a statewide mental health screening process for juvenile offenders

OBJECTIVES: This study examined the utility of screening adjudicated juvenile offenders for mental health symptoms at intake to the State of Washington Juvenile Rehabilitation Administration. The authors assessed the ability of a screening measure, the Massachusetts Youth Screening Inventory, second edition (MAYSI-2), to identify youths with mental health problems and co-occurring substance use problems. This study also examined the relationship of these symptoms to treatment utilization both before and after intake to the juvenile justice system. Ethnic and gender differences in the screening results were studied. METHODS: The MAYSI-2 was administered to 1,840 youths consecutively admitted to state custody. Cluster analysis was used to group the youths by mental health symptom status, and the relationship between symptoms and treatment utilization was tested in the groups identified in the cluster analysis. RESULTS: Youths who reported a high level of mental health symptoms, with or without co-occurring substance use problems, were more likely to have received previous mental health treatment than youths with a low level of mental health symptoms. Youths with a high level of mental health symptoms were more likely to receive extraordinary sentences and were thus less likely to be eligible for community transition programs than youths with a low level of mental health symptoms. Significant gender and ethnic differences in mental health symptom reporting on the screening inventory were found. Female offenders were significantly more likely than male offenders to report a high level of symptoms, and Hispanic youths were significantly less likely than youths in other ethnic groups to report a high level of symptoms. CONCLUSIONS: The MAYSI-2 has utility in identifying youths in the juvenile justice system who have mental health problems, and MAYSI-2 results are related to use of treatment services both before and after intake to the juvenile justice system. Ethnic and gender differences in MAYSI-2 reporting must be considered in interpreting mental health screening data.     

Suicidality, depression, and substance abuse in adolescence

The authors assessed the occurrence of suicidal ideation, suicide attempts, major depression, and substance abuse in a sample of 424 apparently healthy college students 16-19 years old. Major depression and substance abuse were independent and interactive risk factors for suicidal ideation and for suicide attempts; substance abuse had a particularly deleterious effect on men. A prolonged desire to be dead was a more specific risk factor for a suicide attempt than was a thought of suicide. The authors conclude that suicidal ideation in the presence of major depression and/or substance abuse in older adolescents should call forth greater concern for lethality.     

Prevalence and determinants of suicide ideation among Lebanese adolescents: Results of the GSHS Lebanon 2005

The current study examined prevalence and risk factors for suicide ideation in 5038 Lebanese adolescents using Global School Health Survey data. Around 16% of Lebanese adolescents thought of suicide. Multivariate logistic regression models showed that risk factors for suicide ideation included poor mental health (felt lonely, felt worried, felt sad or hopeless), substance use (got drunk, used drugs), victimization (was bullied, was sexually harassed), and lack of parental understanding. Recommendations for future research and interventions are discussed.     

Isolating the Association of Sleep,Depressive State,and Other Independent Indicators for Suicide Ideation in United States Teenagers

According to the Centers for Disease Control and Prevention, suicide is the second leading cause of death in American teenagers, and is a growing public health concern. This study uses multivariable logistic regression to investigate the independent relationship between suicide ideation and sleep duration in teenagers using the 2015 Youth Behavior Risk Surveillance Study, controlling for demographic, behavioral, and other factors found to be associated. Sleep durations of 4–5 hours and 6–7 hours per night were associated with approximately 75–80% and 20–40% increased adjusted odds of suicide ideation, as compared to teens sleeping the recommended 8 hours or more, and should be considered as a potential important indicator for adolescent suicidal ideation in primary-care screens.     

Risk for suicide attempts among adolescents who engage in non-suicidal self-injury.

The current study examined whether common indicators of suicide risk differ between adolescents engaging in non-suicidal self-injury (NSSI) who have and have not attempted suicide in an effort to enhance clinicians' ability to evaluate risk for suicide within this group. Data were collected from 540 high school students in the Midwest who completed the RADS, RFL-A, SIQ, and SHBQ as part of a larger adolescent risk project. Results suggest that adolescents engaging in NSSI who also attempt suicide can be differentiated from adolescents who only engage in NSSI on measures of suicidal ideation, reasons for living, and depression. Clinical implications of the findings are discussed.     

Book Reviews

This study clarified the association of maladaptive, potentially self-damaging behaviors with suicidality. Specifically, we examined whether greater frequency (i.e., how often) or greater versatility (i.e., how many ways) of several self-damaging behaviors, including non-suicidal self-injury (NSSI), substance use, and disordered eating, increased risk for suicide. Participants who engaged in NSSI (N = 142) completed questionnaires assessing suicidal and self-damaging behavior at baseline and engagement in suicidal behaviors (e.g., ideation, attempts, talking about suicide) 3 months later. Results suggest that the versatility rather than frequency of self-damaging behaviors is most robustly associated with suicide risk. Engaging in multiple methods of NSSI and using a greater number of illicit substances were positively associated with suicide risk. Further, versatility of NSSI interacted with depression to predict suicide risk at 3-month follow-up such that highly depressed participants who engaged in more methods of NSSI exhibited highest risk, whereas those who engaged in more methods with low depression exhibited the lowest risk.     

Sex and race differences in mental health symptoms in juvenile justice: the MAYSI-2 national meta-analysis

OBJECTIVE: Studies have suggested a high prevalence of mental health symptoms among youths in the juvenile justice system, with the highest prevalence among girls and whites compared to boys and other races. This multisite, archival study examined whether sex and race differences, when they exist, were consistent across U.S. juvenile justice programs. METHOD: Data included scores on the Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2) for 70,423 youths from 283 juvenile justice probation, detention, or corrections programs. A meta-analytic technique investigated the consistency of effect sizes for sex and race/ethnic differences across sites in self-reported mental health problems; RESULTS: Across sites, girls on average were 1.8 (95% confidence interval 0.98-1.10) to 2.4 (95% confidence interval 2.38-2.48) times as likely as boys to have clinical elevations on all applicable MAYSI-2 scales except the Alcohol/Drug Use scale. On the Alcohol/Drug Use scale, a sex effect existed but only among youngeryouths. Whites were more likely to have clinical elevations than blacks or Hispanics; but surprisingly disparities varied across mental health categories and varied considerably across sites. CONCLUSION: At the aggregate level, 72% of girls and 63% of boys had a clinical elevation on at least one MAYSI-2 scale. Our meta-analytic technique indicated that the sex differences across sites were even larger than these numbers imply. Conversely and counter to existing evidence, race-related differences were generally small or nonexistent. Whites were more likely to have alcohol and drug problems and suicide ideation, but not more likely to have symptoms of depression, anxiety, or thought disturbance than blacks or Hispanics.     

Suicidal ideation and suicide attempts in a sample of homeless people with mental illness

This study utilized data from the national ACCESS program (N = 7224) to investigate the prevalence of suicidal ideation and suicide attempts in a sample of homeless people with mental illness. The prevalence of suicidal ideation in this sample was high (66.2% lifetime prevalence). In addition, 51.3% of the sample reported that they had ever attempted suicide, 26.9% reported an attempt that resulted in a nonpsychiatric hospitalization, and 8% reported an attempt in the previous 30 days. Youth, substance abuse, and psychiatric symptoms were all significantly associated with suicide attempts. Those who reported a recent attempt also reported higher rates of mental health care utilization, particularly inpatient care. The authors conclude that homeless people with mental illness are at particularly high risk for suicidal behavior, however, only in part because of the high prevalence of traditional risk factors.     

Alcohol,cannabis and other drugs and subsequent suicide ideation and attempt among young Mexicans

ObjectiveTo report results from a follow-up study of alcohol, cannabis and other drugs on suicidal behavior.MethodWe estimated prospective associations of substance use as a risk factor for incident suicide ideation and attempt, from a follow-up conducted in 2013 (n = 1071) of the original Mexican Adolescent Mental Health Survey conducted in 2005.ResultsCannabis use before age 15 (ideation risk ratio (RR) = 3.97; 95% confidence interval (CI) = 1.43–11.03; attempt RR = 5.23; 95% CI = 1.17–23.32), early onset of DSM-IV drug use disorder (DUD) among cannabis users (ideation RR = 3.30; 95% CI = 1.11–9.84; attempt RR = 4.14; 95% CI = 1.28–13.36), high frequency of cannabis use (RR for attempts = 4.60; 1.03–20.60) and recent DSM-IV-DUD among cannabis users (RR for attempts = 4.74; 1.09–20.57) increased the RR. For “other drug use”, significant results were found among those with high frequency use of other drugs such that they had a higher RR of suicide attempt (5.04; 1.03–24.64). For alcohol, only those who initiated alcohol before age 15 had higher RRs of suicide attempt (1.79; 1.00–3.20).DiscussionThose who used cannabis at an early age, early onset of DSM-IV-DUD, and those with heavy cannabis use and recent DSM-IV-DUD among cannabis users in the last 12-months had increased risk of suicide ideation and attempt. Drugs other than cannabis showed some of these associations, but to a lesser degree. Prevention of substance use and treatment of those already engaged in drug use, by decreasing suicide ideation and attempt, may help to prevent suicide in Mexico.     

Suicidality in the prospective Zurich study: prevalence,risk factors and gender

Our prospective Zurich study (1978–2008) found that suicidal ideation had occurred in 40.5 % and suicide attempts in 6.6 % of the population by age 50. Important gender differences were found in both suicidality and its risk factors. Suicide attempts were earlier and more frequent among women than among men: 70 versus 44 % reported their first suicide attempt before 20. For women, the relative risk of suicide attempts was 1.6, but the relative risk of suicidal ideation was about equal (1.1 for women). The main risk factors for suicidal ideation in women were low social support (OR 4.0) and frequent punishment in childhood (OR 3.7), and in men, a depressive (OR 6.5) and an anxious personality (OR 4.6). The main risk factors for suicide attempts in women were a broken home (OR 10.2) and sexual abuse/violence (OR 7.9) in childhood; in men, no multivariate analyses of suicide attempt were conducted because of insufficient statistical power.     

Suicide attempt characteristics, diagnoses, and future attempts: comparing multiple attempters to single attempters and ideators

OBJECTIVE: To compare psychiatric diagnoses and future suicide attempt outcomes of multiple attempters (MAs), single attempters (SAs), and ideators. METHOD: Two hundred twenty-eight teens who reported recent ideation or a lifetime suicide attempt in a screening of 1,729 high school students completed the Adolescent Suicide Interview, which provided information on attempt number and characteristics and mood, anxiety, and substance use disorder modules of the Diagnostic Interview Schedule for Children; 191 were reinterviewed 4 to 6 years later to ascertain interval attempts and psychiatric disorder. Between screening and follow-up, 33 (17%) teens made an attempt, 12 of whom were previously classified as lifetime MAs (more than one attempt) and six as SAs. RESULTS: MAs more often met criteria for any one of the DSM diagnoses assessed at baseline (mood, anxiety, or substance use disorder; 71%), compared with SAs (39%) and ideators (41%), and at follow-up (mood, anxiety, substance use, or disruptive behavior disorder; 69%) compared with SAs (36%) (p <.05). As reported at baseline, MAs (versus SAs) more often wished to die during their attempt (53% versus 23%), less often planned their attempt for intervention (44% versus 76%), and more often regretted recovery (26% versus 7%; p <.05). Baseline MAs had significantly higher odds of making a later attempt compared to ideators (odds ratio 4.0, 95% confidence interval 1.5-10.2) and SAs (odds ratio 4.6, 95% confidence interval 1.0-20.2). No participants committed suicide during follow-up. SAs who made another attempt (versus those who did not) more often met criteria for a baseline anxiety disorder and more often wished to die during their baseline attempt. CONCLUSIONS: MAs more strongly predict later suicidality and diagnosis than SAs and ideation. Forms that assess past suicide attempts should routinely inquire about frequency of attempts. The similarity between the present findings and those of clinical samples suggests that screening may yield a representative sample of suicide attempters and ideators.     

The Columbia Suicide Screen: validity and reliability of a screen for youth suicide and depression

OBJECTIVE: This study reports on the psychometric properties of a brief, self-administered screening questionnaire, the Columbia Suicide Screen (CSS), intended to identify high school students at risk for suicide. METHOD: Seventeen hundred twenty-nine 9th- to 12th-grade students completed the CSS and Beck Depression Inventory during school hours in 1991 to 1994. Three hundred fifty-six students who screened positively and 285, group matched on age, gender, and ethnicity, who screened negatively were examined on the Diagnostic Interview Schedule for Children (DISC), version 2.3, to assess validity. The DISC-based suicide risk criterion was suicidal ideation or prior suicide attempt and a DSM-III-R diagnosis of major depression or dysthymia or substance use. Test-retest reliability was assessed in a subsample of 85. RESULTS: The most balanced algorithm had a sensitivity of 0.75, specificity 0.83, and positive predictive value 16%. Suicidal ideation and prior attempt item reliabilities (kappa) were 0.48 and 0.58, respectively. Eight-day test-retest reliability for the most balanced scoring algorithm was 0.32. CONCLUSIONS: The CSS demonstrated good sensitivity and reasonable specificity identifying students at risk for suicide. A second-stage evaluation would be needed to reduce the burden of low specificity.     

Relative social standing and suicide ideation among Kenyan males: the interpersonal theory of suicide in context

Purpose

The purpose of this study is to investigate the association between subjective social status and suicide ideation in a sample of young Kenyan men (age 18–34 years). Situating insights from the interpersonal theory of suicide within social determinants of health framework, we consider whether lower subjective social status predicts lower collective self-esteem (CSE), hopelessness, less meaning in life and more loneliness, and whether these characteristics mediate associations between subjective social status and suicide ideation.

Method

A community-based, semi-rural sample (n = 532) of young men, aged 18–34 years, was collected using a standardized questionnaire. The survey questionnaire included the following validated scale items: the short form of the Social and Emotional Loneliness Scale for Adults, CSE, Herth Hope Index, the Meaning in Life Questionnaire, and the Modified Scale for Suicide Ideation. Regression and mediation analyses were used to test hypotheses.

Results

Nearly 12% of respondents reported suicide ideation. Suicide ideation was significantly more common among survey respondents who reported lower subjective social standing. In the first of two mediation models, we found that lower CSE and more loneliness mediate the association between lower subjective social status and suicide ideation. In the second model, we found that respondents with lower CSE and more loneliness expressed lower hope and meaning in life, which also mediated pathways to suicide ideation.

Conclusions

Findings show a novel synthesis of social determinants literature with the interpersonal theory of suicide. Suicide ideation, along with other mental and social outcomes, may figure more prominently than previously appreciated in the benefits of socio-economic equality. Those who do not participate equally in socio-economic development may be at greater risk of engaging in suicide ideation and behaviors. Suicide prevention research and programmatic responses should adopt a health equity perspective to ensure that prevention is targeted where people are more likely to engage in suicide ideation.

     

Predictors of Suicide Attempt Status: Acquired Capability,Ideation, and Reasons

The present study compared Non-Attempters, Recent Attempters, and Distant Attempters on the following three constructs: Acquired capability for suicide, reasons for attempting suicide (internal perturbation based reasons vs. extrapunitive/manipulative reasons), and suicidal ideation. Participants were 40 Non-Attempters, 28 Recent Attempters, and 32 Distant Attempters at three state psychiatric hospitals. The sample consisted of 63 males and 37 females ranging in age from 18 to 63 years (M = 35.84, SD = 11.44). All patients completed the self-report measures. There were significant differences between the groups on suicidal ideation and acquired capability for suicide. The results of the present study indicate that acquired capability and reasons for attempting suicide have considerable importance for understanding suicide risk. Integration of acquired capability for suicide and reasons for attempting suicide into assessment and treatment is warranted.     

Hopelessness,depression, substance disorder,and suicidality

Abstract. Background: Most earlier studies of hopelessness as a risk factor for suicidal behavior were based on either clinical or restricted samples. Using a longitudinal study design with a community sample of more than 3,000 participants, we aimed to examine if hopelessness was a long-term predictor of suicidal behaviors. Methods: Using longitudinal data from the Baltimore Epidemiologic Catchment Area (ECA) Program, we assessed the association of hopelessness at baseline and incident suicidal behaviors in the 13-year follow-up period, adjusting for the presence of depression and substance use disorders. Suicide behaviors studied included completed suicide, self-reported attempted suicide, and suicide ideation. Results: Hopelessness was predictive of all three types of suicidal behaviors in the follow-up period, even after adjustment. Persons who expressed hopelessness in 1981 were 11.2 times as likely to have completed suicide over the 13-year follow-up interval (95% confidence interval [1.8, 69.1]). The association between suicidality and hopelessness was stronger and more stable than the association of suicidality with the presence of depression and substance use disorders. Conclusion: Hopelessness was an independent risk factor for completed suicide, suicide attempts, and suicidal ideation. Intervention strategies that lower hopelessness may be effective for suicide prevention.Dr. Kuo is currently with Medical and Health Research Association (MHRA) and National Development and Research Institute, Inc (NDRI), New York, NY, USA. Dr. Gallo is currently with the Department of Family Practice and Community Medicine, University of Pennsylvania, Philadelphia, PA, USA.