Risk Factors for Adolescent Suicide and Suicidal Behavior: Mental and Substance Abuse Disorders,Family Environmental Factors,and Life Stress

This review focuses on psychopathologic risk factors for adolescent suicide and suicidal behavior, namely, affective, disruptive, substance abuse, psychotic, and personality disorders. The interaction of psychopathology with age and gender is discussed. The role of family environmental risk factors and stress events in suicide and suicidal behavior, both alone, and in interaction with psychopathology are reviewed. Research reviewed will include psychological; autopsy studies, longitudinal studies examining predictors of suicide, and epidemiologic studies of suicide attempts.     

The cultural theory and model of suicide

A growing body of research has demonstrated important variations in the prevalence, nature, and correlates of suicide across ethnic and sexual minority groups. Despite these developments, existing clinical and research approaches to suicide assessment and prevention have not incorporated cultural variations in any systematic way. In addition, theoretical models of suicide have been largely devoid of cultural influence. The current report presents a comprehensive analysis of literature describing the relationship between cultural factors and suicide in three major ethnic groups (African Americans, Asian Americans, and Latinos) and LGBTQ¹ sexual minority groups. We utilized an inductive approach to synthesize this variegated body of research into four factors that account for 95% of existing culturally specific risk data: cultural sanctions, idioms of distress, minority stress, and social discord. These four cultural factors are then integrated into a theoretical framework: the Cultural Model of Suicide. Three theoretical principles emerge: (1) culture affects the types of stressors that lead to suicide; (2) cultural meanings associated with stressors and suicide affect the development of suicidal tendencies, one's threshold of tolerance for psychological pain, and subsequent suicidal acts; and (3) culture affects how suicidal thoughts, intent, plans, and attempts are expressed. The Cultural Model of Suicide provides an empirically guided cohesive approach that can inform culturally competent suicide assessment and prevention efforts in future research and clinical practice. Including both ethnic and sexual minorities in our investigations ensures advancement along a multiple identities perspective.     

Forgiveness,Depression, and Suicidal Behavior in Adolescents: Gender Differences in this Relationship

With the development of positive psychology, protective factors have received increased attention as buffers against suicidal ideation and attempts and against the risk factors for suicide (e.g., depressive symptoms). Empirical evidence suggests that one of the protective factors associated with depression and suicide is forgiveness. Although previous studies have demonstrated a negative association between forgiveness and risk of suicide, studies on gender differences in adolescents are still scarce. Thus, the authors assessed the moderating role of gender in a sample of adolescents. The participants were 572 adolescents (50.9% boys; M age = 15.49 years, SD = 1.09 years) from secondary school centers. The results revealed that forgiveness moderated the relationship between depression and suicidal ideation for boys but not for girls. Specifically, for boys the relationship between depression and suicidal thoughts and behaviors weakened as levels of forgiveness increased. These findings suggest therapeutic applications to reduce the likelihood of suicide in the group of adolescent boys with higher scores on depression and lower levels of forgiveness. The study results are discussed in terms of the need to use gender perspectives in positive psychology intervention programs.     

Differences in nonfatal suicide behaviors among Mexican and European American middle school children.

This report describes ethnic and gender differences in suicide ideation among two large samples of middle school students in New Mexico (n = 2,140) and Texas (n = 1,302). Students completed a self-administered questionnaire on suicide ideation and psychosocial risk factors. Mexican Americans in both samples reported significantly higher prevalence of suicide ideation than did their European American counterparts. Mexican Americans were 1.8 times more likely to have high suicide ideation than European Americans. The suicide ideation risk for Mexican Americans remained unchanged in both samples after adjusting for gender, age, family structure, depression, low social support, and self-esteem. This study indicates that ethnicity plays an important role in suicidal ideation, but the mechanism remains unclear.     

Body image and suicidal ideation in adolescents

Data from 231 adolescents (mean age = 15.7, SD = 1.39) were collected from a public school setting in the United States. Participants completed several measures, including those assessing depression, hopelessness, past suicidal behavior, body image, and current suicidal ideation. It was hypothesized that depression, hopelessness, past suicidal behavior, and body image (a risk factor seldom examined) would significantly predict current suicidal ideation and that there would be gender differences for body image. Regression analyses indicated that all risk factors including body image were significant predictors of current suicidal ideation for the whole sample. For both males and females, body image offered a unique contribution to the measurement of suicide ideation above and beyond the other risk factors, with body attitudes/feelings being the strongest predictor. Results encourage the inclusion of body image as a variable in risk models for adolescent suicidal ideation, as it likely accounts for additional variance above and beyond traditional risk factors.     

The Great Black Hope: Hope and Its Relation to Suicide Risk among African Americans

Positive psychology has garnered considerable scholarly interest recently and has been suggested to hold promise in the application to suicide research and prevention; however, empirical research has lagged behind these suggestions. This is the first study to examine the relationship between hope and a specific theory of suicide in African Americans. It was hypothesized that (1) hope would negatively predict the interpersonal suicide risk factors of burdensomeness and thwarted belongingness; and positively predict acquired capability to enact suicide; (2) hope would negatively predict suicidal ideation; and (3) the interpersonal suicide risk factors would predict suicidal ideation. Results were primarily as predicted. Implications for hope theory and Joiner's theory of suicidal behavior are discussed, as well as implications for clinical practice.     

10 Suicidality Among Acculturating Mexican Americans: Current Knowledge and Directions for Research

Despite the dramatic increase in Mexican-American immigration over the past two decades, the acculturative experience and its relationship to suicide risk have received little attention within the field of suicidology. This paper summarizes findings from community-based studies that have explored suicide and risk factors among immigrant and Mexican-American groups, and suggests directions for future research. Most of these studies have been epidemiologic, and relatively few have addressed risk and protective factors within well-defined acculturating groups. Further study of the full continuum of suicidal thoughts and behaviors that examines precise cultural risk factors, and uses methodologies that combine quantitative and qualitative data, may improve our understanding of suicide risk among acculturating Mexican Americans.     

African American and Caucasian attempters compared for suicide risk factors: a preliminary study

The aim of the study was to compare African American and Caucasian substance dependent suicide attempters for risk factors for suicidal behavior. One hundred and fifty-eight African American and 95 Caucasian substance dependent patients who had attempted suicide were interviewed and their family history of suicidal behavior recorded. Patients completed the Childhood Trauma Questionnaire, the Eysenck Personality Questionnaire, and the Foulds Hostility and Direction of Hostility Questionnaire. The results revealed that there were no significant differences between the African American and Caucasian suicide attempters for marital status, age, childhood abuse, or for personality scores for neuroticism, extraversion, psychoticism, or hostility. However, the African American attempters had significantly lower childhood emotional neglect scores. Also, significantly more of the Caucasian attempters had a family history of suicide and current legal problems. Further studies seem warranted examining for differences between African Americans and Caucasians for risk factors for suicidal behavior.     

The Gender Paradox in Suicide

In most Western countries females have higher rates of suicidal ideation and behavior than males, yet mortality from suicide is typically lower for females than for males. This article explores the gender paradox of suicidal behavior, examines its validity, and critically examines some of the explanations, concluding that the gender paradox of suicidal behavior is a real phenomenon and not a mere artifact of data collection. At the same time, the gender paradox in suicide is a more culture-bound phenomenon than has been traditionally assumed; cultural expectations about gender and suicidal behavior strongly determine its existence. Evidence from the United States and Canada suggests that the gender gap may be more prominent in communities where different suicidal behaviors are expected of females and males. These divergent expectations may affect the scenarios chosen by females and males, once suicide becomes a possibility, as well as the interpretations of those who are charged with determining whether a particular behavior is suicidal (e.g., coroners). The realization that cultural influences play an important role in the gender paradox of suicidal behaviors holds important implications for research and for public policy.     

Suicidal behavior inLatinas: explanatory cultural factors and implications for intervention

We posit that the high rates of suicidal behavior by teenage Hispanic females reported in large-scale surveys can be understood as a cultural phenomenon, a product of specific elements of the history, tradition, ideology, or social norms of a particular society, and that treatment interventions must take family and cultural factors into consideration. For over a decade, surveys have reported that among ethnic and racial minority youth in the United States, Latinas have the highest rates of suicidal behavior compared to African American and non-Hispanic White adolescent females. However, other research shows that the psychological profiles of suicidal Latina adolescent girls and the risk factors for Latina suicidal behavior may not be that different from non-Hispanic suicidal adolescent females. The unique situation of adolescent Latinas involves the convergence of cultural and familial factors (i.e., familism, acculturation, relatedness, autonomy, etc.) with the developmental, social, and individual factors frequently associated with suicidal behaviors. Based on this background, family-oriented interventions appear to be the most appropriate approach to the prevention and treatment of Hispanic suicidal girls. Factors implicated in Latina suicidal behavior and community-based interventions that include the adolescent and her family are suggested.     

Suicidal Behavior in the Western Pacific Region: Characteristics and Trends

Current knowledge of suicidal behavior in the Western Pacific region is relatively limited when compared to other areas of the world. This area is characterized by a wide diversity of social, economic, and cultural aspects that do not permit any homogenous reading of suicide phenomena. Data from countries of the region included in this article suggest the existence of important differences among nations in terms of gender, age, and methods of suicide, as well role of mental illness. In addition, the Western Pacific region appears to be affected by higher rates of suicide than other areas in the world, with signs of progressive worsening in recent years and worrying predictions for the next two decades. The Suicide Trends in At‐Risk Territories (START) Study, initiated by the World Health Organization Regional Office in Manila, seeks to research the incidence of both fatal and nonfatal suicidal behavior in countries of the region and to implement interventions for suicide attempters. This ambitious project is expected to standardize data collection procedures and improve the knowledge cultural factors in suicide.     

Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention

Suicidal behavior is frequent in patients with borderline personality disorder (BPD); at least three-quarters of these patients attempt suicide and approximately 10% eventually complete suicide. Borderline patients at greatest risk for suicidal behavior include those with prior attempts, comorbid major depressive disorder, or a substance use disorder. Comorbidity with major depression serves to increase both the number and seriousness of the suicide attempts. Hopelessness and impulsivity independently increase the risk of suicidal behavior, as does a turbulent early life and the presence of antisocial traits. In summary, because BPD is frequently complicated by suicidal behavior, clinicians must avoid the mistake of thinking that a pattern of repeated attempts indicates little desire to die. Clinicians have an important role in preventing suicide attempts and completed suicides by understanding the risk factors.     

Suicidal Ideation of Psychiatrically Hospitalized Adolescents has One-Year Predictive Validity for Suicide Attempts in Girls Only

Clinicians commonly incorporate adolescents’ self-reported suicidal ideation into formulations regarding adolescents’ risk for suicide. Data are limited, however, regarding the extent to which adolescent boys’ and girls’ reports of suicidal ideation have clinically significant predictive validity in terms of subsequent suicidal behavior. This study examined psychiatrically hospitalized adolescent boys’ and girls’ self-reported suicidal ideation as a predictor of suicide attempts during the first year following hospitalization. A total of 354 adolescents (97 boys; 257 girls; ages 13–17 years) hospitalized for acute suicide risk were evaluated at the time of hospitalization as well as 3, 6, and 12 months later. Study measures included the Suicidal Ideation Questionnaire-Junior, Multidimensional Anxiety Scale for Children, Children’s Depression Rating Scale-Revised, Beck Hopelessness Scale, Youth Self-Report, and Personal Experiences Screen Questionnaire. The main study outcome was presence and number of suicide attempt(s) in the year after hospitalization, measured by the Diagnostic Interview Schedule for Children. Results indicated a significant interaction between suicidal ideation, assessed during first week of hospitalization, and gender for the prediction of subsequent suicide attempts. Suicidal ideation was a significant predictor of subsequent suicide attempts for girls, but not boys. Baseline history of multiple suicide attempts was a significant predictor of subsequent suicide attempts across genders. Results support the importance of empirically validating suicide risk assessment strategies separately for adolescent boys and girls. Among adolescent boys who have been hospitalized due to acute suicide risk, low levels of self-reported suicidal ideation may not be indicative of low risk for suicidal behavior following hospitalization.     

African American children's reports of depressed mood, hopelessness, and suicidal ideation and later suicide attempts

This study attempted to assess whether family demographic characteristics and child aggressive behavior are equal to or better than child self-reported depressive symptoms in predicting suicidal behavior. Participants were a community population of African Americans first recruited at age 6 and followed periodically through age 19-20. Measures included child self-reports of depressed mood, hopelessness, and suicidal ideation, teacher reported child aggression in grades 4-6, 6 th grade caregiver report of family demographic characteristics, and the participants' report at age 19-20 of suicide attempts. Depressed mood proved the most consistent predictor of adolescent/young adult attempts in our logistic regression analyses of the data from the population as a whole and among females. The relationship between depressed mood and suicide attempts in males was in the expected direction, but was not statistically significant. Teacher-reported youth aggressive behavior did prove to be a significant predictor of attempts in 4 th and 5 th grade for the population as a whole, but not in our analyses by gender. The relationships between family demographic characteristics and attempts failed to reach statistical significance, but were, generally, in the expected direction. The study revealed that African American children's self-reports of depressed mood as early as grade 4 may prove useful in predicting adolescent/young adult suicide attempts, particularly among females. Neither family demographics nor teacher-reported child aggressive behavior proved equal to child self-reported depressive symptoms in predicting later suicide attempts.     

童年期心理虐待与忽视对高中生自杀意念的影响：述情障碍的中介作用和寻求意义感的调节作用

为了探讨童年期心理虐待与忽视与自杀意念之间的关系及其作用机制,本研究采用心理虐待与忽视量表、多伦多述情障碍量表、青少年自杀意念量表及生命意义感量表中的寻求意义感分量表对1074名高中生进行调查。结果表明：（1）童年期心理虐待与忽视对自杀意念有正向预测作用,并且能够通过述情障碍的中介作用影响高中生自杀意念;（2）寻求意义感调节了这一中介过程的直接路径和后半段路径,对后半段路径的调节作用存在性别差异。     

Does Culture Make a Difference? Racial/Ethnic Patterns of Completed Suicide in San Francisco,CA 1987–1996 and Clinical Applications

Completed suicides in San Francisco were examined in the racial groups of African Americans, Asians, Caucasians, Hispanics, and Native Americans for a 10-year period (1987–1996). Comparisons of rates across race and gender showed that both Caucasian men and women had the highest rates. Significant differences were found when racial groups were compared across age groups, gender, and method, but no significant difference was found in the use of firearms as a method of suicide. Differences and similarities are illustrated by comparing Caucasian and Asian patterns of suicide in the areas of (1) suicide in Asian homelands, (2) cultural context, and (3) cultural beliefs regarding psychopathology. A framework relating cultural variables to predisposing client variables is suggested for clinicians and researchers.     

The relationship between seriously considering, planning, and attempting suicide in the youth risk behavior survey

The assumed ordinal relationship between seriously considering, planning, and attempting suicide in the 1999 Youth Risk Behavior Survey was examined by constructing a trajectory that identified all possible response patterns among the four questions measuring suicidal activity. Statistical analysis tested for differences in frequency of risk behaviors across levels of the trajectory. Overall, the trajectory provided insight to the progression of adolescent suicidal activity and demonstrated usefulness as a measure of suicidal intent. Significant differences between means of dependent variables at each level of the normative trajectory supported the hypothesis that frequency of risk behaviors increases monotonically with successive suicidal thought and behavior.     

Factors in the assessment of suicidality in youth

Suicide remains a leading cause of death among youth, and suicide ideation and behavior are relatively common in both normal and clinical populations. Clinicians working with young people must assess for the presence of suicidal ideation, suicidal behavior, and other risk factors, in order to determine the level of risk. This paper provides the clinician with a summary of risk factors for youth suicide, as well as providing standardized terminology to enhance assessment of suicidal ideation and behavior.     

Adolescents' Attitudes About the Role of Mental Illness in Suicide,and Their Association with Suicide Risk

We examined teenagers' attitudes about the role of mental illness in suicidal behavior and the relationship between these attitudes and suicide risk. Serious suicidal ideation or behavior and associated risk factors (gender, depression, substance problems, and first‐hand experience with a suicidal peer) were assessed in 2,419 students at six New York high schools. Less than one fifth of students thought that mental illness was a major contributor to suicide. Suicidal adolescents and those at risk were less likely than their nonsuicidal and low‐risk counterparts to associate suicide with mental illness. Our findings contribute to the debate over whether accepting attitudes toward suicide increase suicide risk.