RESEARCH ARTICLEOpen Access
Thoughts of death or suicidal ideation are
common in young people aged 12 to 30 years
presenting for mental health care
Elizabeth M Scott1,2, Daniel F Hermens1*, Sharon L Naismith1, Django White1, Bradley Whitwell1, Adam J Guastella1,
Nick Glozier1and Ian B Hickie1
Background: Reducing suicidal behaviour is a major public health goal. Expanding access to care has been
identified as a key strategy. In Australia, a national network of primary-care based services (headspace) has been
established for young people with mental ill-health. This study determines the socio-demographic,
psychopathological and illness-stage correlates of suicidal ideation in young persons attending headspace services.
Methods: Suicidal ideation was recorded using the specific suicide item of the Hamilton Depression Rating Scale
(HDRS) in a cohort of subjects aged 12-30 years (N= 494) attending headspace services.
Results: Of the 494 young persons assessed, 32% (158/494) had a positive response to any level of the HDRS
suicide item, consisting of 16% (77/494) reporting that life was not worth living and a further 16% (81/494)
reported thoughts of death or suicidal ideation. Young women (19%; 94/494) were more likely to report any
positive response as compared with young men (13%; 64/494) [χ2(2,494) = 13.6, p < .01]. Those with ‘attenuated
syndromes’ reported positive responses at rates comparable to those with more established disorders (35% vs. 34%;
χ2(1,347)= 0.0, p =0.87). However, more serious levels of suicidal ideation were more common in those with
depressive disorders or later stages of illness. In multivariate analyses, the major predictors of the degree of suicidal
ideation were increasing levels of clinician-rated depressive symptoms (beta= 0.595, p < .001), general
psychopathology (beta= 0.198, p < .01), and self-reported distress (beta= 0.172, p <.05).
Conclusions: Feelings that life is not worth living, thoughts of death or suicidal ideation are common in young
people seeking mental health care. These at-risk cognitions are evident before many of these individuals develop
severe or persistent mental disorders. Thoughts of death or suicidal ideation may well need to be a primary
intervention target in these young people.
Keywords: Suicide, Clinical staging, Psychiatric, Youth
While approximately six per cent of deaths globally in
those aged 10-24 years are due to suicide , attempted
suicide and related injuries also contribute significantly to
the overall burden of illness in young people [2-4]. Suicide
increases significantly after the age of 15 years and con-
tinues to rise in early adulthood . Previous Australian
data suggested that increasing access to treatments might
have reduced completed suicides in the late 1990s .
While a range of population-based strategies are relevant
for suicide prevention, enhanced access to quality services
for young people with mental disorders has been priori-
In Australia, however, access to appropriate mental
health care is less likely to occur in males and young
people, and is also adversely affected by lower socio-
economic status and living outside of the major metro-
politan centres [6-8]. Previous studies have indicated the
extent to which a variety of factors including how young
people perceive common disorders like depression and
* Correspondence: email@example.com
1Clinical Research Unit, Brain & Mind Research Institute, University of Sydney,
100 Mallet Street, Camperdown, NSW 2050, Australia
Full list of author information is available at the end of the article
© 2012 Scott et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Scott et al. BMC Psychiatry 2012, 12:234
suitability of available services or treatments , or how
young people interact with primary care services ,
affect the probability that young people will use services
or receive appropriate mental health care.
The development of the new national youth mental
health services framework, headspace [10,11], has as one
of its goals easier and earlier access to care for young
people who are experiencing mental ill-health. Specifically,
it is designed to attract those who may be at high risk -
such as young men with concurrent alcohol or other sub-
stance misuse or those who might be experiences thoughts
of self-harm or suicide. The aims of this study are to assess
data collected from a large, representative headspace
population and to evaluate the relationships between self-
reported suicidal ideation and key risk factors, such as
gender and substance use. Additionally, the potential rela-
tionships between suicidal risk factors and other demo-
graphic, diagnostic or illness-stage variables have not been
explored in this unique youth cohort who are presenting
for care early in the course of mental ill-health.
The study and consent procedure was approved by the
University of Sydney Human Research Ethics Committee
(USYD HREC). All participants were determined by their
referring clinician or mental health professional to have
the mental and intellectual capacity to give written
informed consent prior to participation in the study. Parti-
cipants aged 16 years or older were able to give their own
written informed consent (i.e. parental/guardian consent
is not required for those aged 16 and above according to
the USYD HREC guidelines and Australian law) prior to
participation in the study. Parental (or guardian) written
consent was obtained for subjects under 16 years of age.
Four-hundred and ninety-four outpatients were recruited
from two headspace services that specialise in the assess-
ment and early intervention of mental health problems in
young people [11,12]. Importantly, the key inclusion cri-
teria for this study were not focused on issues related to
self-harm or suicidal behaviour. The two key inclusion cri-
teria were: (i) persons aged 12 to 30 years seeking profes-
sional help primarily for anxiety, depressive and/or
psychotic symptoms that were associated with self-
reported impairments in role function; and, (ii) willingness
to participate in more detailed clinical, neurobiological
and longitudinal research related to illness outcomes in
young people [13,14]. Participants were consecutively
recruited between October 2007 and December 2011; and
were excluded if they had insufficient fluency in the English
language to participate in the neuropsychological assess-
ment (not reported here), were intellectually impaired
(e.g. IQ<70) or had current substance dependence.
Participants were asked to abstain from drug and alcohol
use for 48 hours prior to testing. Referring clinicians were
asked to determine primary and secondary diagnoses based
on DSM-IVcriteria. For the purposes of this study, patients
were then grouped into the relevant broad categories (pri-
mary diagnoses) of ‘depression’ , ‘bipolar’ , ‘psychosis’ , and
‘other’ (which included anxiety-, behavioural-, autistic
spectrum-, learning-, substance use-, and personality-
Following earlier clinical assessment and active illness
management by the referring clinician (i.e. a psychiatrist,
clinical psychologist or general practitioner with training
in mental health), a trained research psychologist con-
ducted a structured clinical interview in this sub-group
of subjects to record details of the nature and history of
any mental health problems. As a proxy measure for
duration of illness, the age that each patient first
engaged a mental health service was recorded. The
interviewer completed the Brief Psychiatric Rating Scale
(BPRS; ) to quantify general psychopathology and
the Hamilton Depression Rating Scale (HDRS)  to
rate severity of depressive symptoms. The third item of
the HDRS was utilised to determine the level of a
patient’s current suicidal thoughts or ideation. Specific-
ally the item was asked as follows: “This past week, have
you had any thoughts that life is not worth living? What
about thinking you’d be better off dead? Have you had
thoughts of hurting or killing yourself?” (If answered
“yes”, a further prompt was: “What have you thought
about? Have you actually done anything to hurt your-
self?”). Ratings were then based on the following scores:
0 =‘absent’; 1 = ‘feels life is not worth living’; 2= ‘wishes
s/he were dead or any thoughts of possible death to self’;
3 =‘suicidal ideas or gestures’ and 4 = ‘attempts at suicide
(any serious attempt)’. The social and occupational func-
tioning assessment scale (SOFAS; ) was also used as
a rating of the patient’s functioning from 0 to 100, with
lower scores indicating more severe impairment.
Our clinical staging model  builds on routine clinical
assessment (though it may be assisted by ancillary investi-
gations). A stage of illness is formally assigned at the end of
the clinical assessment phase. Such clinical assessment cap-
tures: (i) current major symptoms (severity, frequency,
type); (ii) characteristic mental features; (iii) age of onset
and clinical course of illness prior to presentation; (iv) pre-
vious “worst ever” symptoms and treatments including hos-
pital admissions; (v) current level of risks of harm due to
illness; (vi) previous suicide attempts or other at-risk beha-
viours; and, (vii) current (as compared with premorbid)
levels of social, educational or employment functioning.
Scott et al. BMC Psychiatry 2012, 12:234
Page 2 of 6
Once this information is obtained and integrated, a clinical
stage is assigned according to sets of established criteria
(see ). As described in detail elsewhere , our staging
model includes five discrete categories: stage 1a=‘help-
seeking’; stage 1b=‘attenuated syndrome’; stage 2=
‘discrete disorder’; stage 3=‘recurrent or persistent dis-
order’; and stage 4=‘severe, persistent and unremitting
Importantly, these stages do not use the same thresholds
for disorder as DSM or ICD-defined anxiety, mood or
psychotic disorders. In previous work , we have demon-
strated that many single episode or uncomplicated DSM-
defined anxiety or depressive disorders are staged as 1a or
1b respectively, while established psychotic, bipolar or se-
vere depressive disorders are likely to be rated as stage 2 or
above (depending on other illness course variables).
Participants completed self-report measures that included
the Kessler-10 (K-10)  which is a brief instrument
designed to detect severity of general psychological dis-
tress and the Alcohol Use Disorders Identification Test
(AUDIT) to assess each participant’s level of risky drinking
in the past year, as well their lifetime familiarity [20,21].
Performed using SPSS for Windows 20.0; group differ-
ences in demographic, clinical and self report variables
were assessed via ANOVA or chi-square tests where rele-
vant. If equality of variance was compromised (according
to Levene’s test) the corrected degrees of freedom and
p-values were reported. Scheffé’s tests were used to deter-
mine post-hoc pair-wise comparisons. To identify the rela-
tive significance of any distinguishing variables (or their
pattern of co-association) of illness factors that were sig-
nificant in the univariate analyses were entered into a final
multiple stepwise regression model.
Among the 494 young persons assessed, 15.6% (77/494)
reported that life was not worth living, while 16.4% (81/
494) reported thoughts of death or suicidal ideation (scored
as 2 or more on the relevant HDRS item); resulting in a
total of 31.9% (158/494) reporting a positive response at
any level of the HDRS suicide item. Notably, the proportion
of positive responders was comparable in both adolescents
(12 to 17 years) and young adults (18 to 30 years) at 30.3%
(51/168) and 32.8% (107/326), respectively. Across the en-
tire sample (i.e. 12 to 30 years), females (19.0%; 94/494)
were more likely to report any positive response as com-
pared with males (12.9%; 64/494) [χ2(2,494)=13.6, p<.01].
As outlined in Table 1, those reporting at-risk phenom-
ena were more likely to be female, assessed by clinicians
to be functioning more poorly and as being more severely
depressed or having more behavioural disturbance, and to
be self-reporting more general distress. Higher levels of al-
cohol use were not a strong predictor of thoughts of death
or suicidal ideation in this cohort. A stepwise multiple re-
gression using the five significant variables (i.e. gender,
SOFAS, HDRS total, BPRS total, K10 total; see Table 1) as
predictors of thoughts of death or suicidal ideation
revealed a three-step model: [R2=0.351 for step 1, change
in R2=0.019 for step 2 (p<.01), change in R2=0.015 for
step 3 (p<.05)]. In step one, only depressive symptoms
(total HDRS; beta=0.595, p<.001) were included in the
model; in step two, behavioural disturbance (total BPRS;
beta=0.198, p<.01) was added; and in step 3, self-
reported distress (total K10; beta=0.172, p<.05) contrib-
uted to the overall model (R2=0.388). That is, both
clinician-rated and self-reported symptom severities, ra-
ther than other demographic or comorbid features,
emerged as strong predictors of thoughts of death or sui-
cidal ideation in this cohort.
The prevalence of individuals reporting any symptom
on the suicide item (i.e. ‘life not worth living’ or ‘thoughts
of death’ or ‘suicidal ideation’) versus those who didn’t
(i.e. ‘absent’) was significantly different across the four
diagnostic groups [χ2(3, 494)=14.7, p<.01] (see Table 2).
Notably, those with depressive disorders reported the
highest rates of any positive response to the suicide item
(41.9%; 78/186). Similarly, the rates of those reporting
thoughts of death or suicidal ideation (i.e. a score of 2 or
more versus 1 or below) was also significantly different
across the diagnostic groups [χ2(3, 494)=13.4, p<.01],
with the depression group having approximately twice the
rate of reporting the more serious symptoms compared to
the remaining three diagnostic groups.
With regards to illness stage, there were significant dif-
ferences in the rates of individuals reporting any symptom
on the suicide item [χ2(3, 481)=9.2, p<.05] and in the
rates of those who reported the more severe thoughts of
death or suicidal ideation [χ2(3, 481)=8.4, p<.05] (see
Table 2). Approximately 35% of those at stage 1b or
greater reported any positive response to the HDRS sui-
cide item. The lack of major difference (i.e. 35.1% vs.
34.3%; [χ2(1,347)=0.0, p=0.87]) between those classed as
being at stage 1b (i.e. attenuated syndromes) versus stage
2/3 (discrete or established disorders) is notable. Within
the 1b category (i.e. below our threshold for established or
persistent disorders), 15.5% of subjects reported overt sui-
cidal ideation (37/239). Even among those rated as being at
the earliest stage of illness (1A) the prevalence of any posi-
tive response to the HDRS suicide item was almost 17%.
Almost a third of young people attending youth-orientated
mental health services and participating in longitudinal re-
search report some degree of suicidal ideation (32%%).
Scott et al. BMC Psychiatry 2012, 12:234
Page 3 of 6
Such thoughts are well-accepted risk factors for later acts
of self-harm or overt suicidal behaviour . Although many
of these individuals do not yet have established mental dis-
orders, the rates of these ‘at-risk’ phenomena are much
higher than in the general population – where cumulative
rates of up to 10% over the entire adolescent or early adult
period may be expected .
Even among those classed as being at the earliest or least
severe phase (stage 1a) of mental ill-health, 17% report
any positive symptom on the suicide-related item. These
prevalence rates rise sharply in those with ‘attenuated syn-
dromes’ (stage 1b, approximately 35%). It is possible that
rates are even higher in those with more established disor-
ders who present to other more specialised mental health
or emergency forms of care. Consistent with that view,
there was a strong relationship in our cohort between se-
verity of depressive and other behavioural symptoms and
degree of suicidal ideation. Indeed, more serious levels of
suicidal ideation were more common in those with de-
pressive disorders or later stages of illness.
In this group of young people, however, it is clear that
thoughts of death or suicidal ideation do occur early in
the course of illness and are not simply restricted to
those with more persistent or severe mental disorders.
Importantly, these data are consistent with the view that
thoughts of death or overt suicidal ideation may be
strong drivers to seeking health-care, independent of
other illness-related factors. This would be consistent
Table 1 Demographic and clinical correlates of suicidal ideation in young people presenting for mental health care
death or Suicidal
Significance Test [p]
a vs. ba vs. cb vs. c
Females, n (%) 145 (43%)41 (53%)53 (65%)
χ2(2, 493)=13.6 [.001]na nana
Age, years 19.9± 4.619.4±4.120.0±4.1 F (2, 493)=0.4 [.706]
Age of onset, years15.4± 4.7 15.4±4.814.1±3.7F (2, 397)=2.5 [.086]
Predicted IQ100.6±11.7 101.4±9.2 102.9± 9.5F (2, 147.6)= 1.6 [.212]
Education, years11.5± 2.811.5±2.511.5±2.5 F (2, 489)=0.1 [.942]
SOFAS 62.4± 12.058.0±11.2 57.0±11.7F (2, 387)=7.2 [.001]* **
HDRS total8.7±5.7 14.8±5.619.0±5.6F (2, 476)=120.7 [.000]*********
BPRS total36.7± 8.643.7±9.8 49.2±10.5F (2, 475)=67.8 [.000]*********
K10 total23.0± 7.430.4±7.833.5±6.1 F (2, 424)=73.8 [.000]*******
AUDIT total 6.9±7.77.5± 8.68.2± 8.5F (2, 491)=0.9 [.399]
Note: Final columns provide the results of the post-hoc Scheffe’s pairwise comparisons (with corresponding significance levels: * < .05; ** p< .01; *** p< .001)
where ‘a’ denotes the “No suicidal ideation” group (i.e. HDRS item-3 score = 0); ‘b’ denotes the “Life not worth living” group (i.e. HDRS item-3 score = 1) and ‘c’
denotes the “Thoughts of death or Suicidal ideation” group (i.e. HDRS item-3 score >1). SOFAS = Social and Occupational Functioning Assessment Scale; HDRS =
Hamilton Depression rating Scale; BPRS = Brief Psychiatric Rating Scale; K-10 = Kessler-10; AUDIT = Alcohol Use Disorders Identification Test.
Table 2 Diagnostic and illness-stage correlates of suicidal ideation in young people presenting for mental health care
“Life not worth
Thoughts of death or Suicidal
Depression58.1 41.9 17.7 24.2 
Bipolar69.6 30.4 20.3 10.1 
Psychosis74.4 25.6 13.2 12.4 
Other76.9 23.1 11.1 12.0 
Stage 1a: help-seeking83.3 16.7  9.7 6.9 
Stage 1b: attenuated syndromes 64.9 35.1 19.7 15.5 
Stage 2: discrete disorder 65.7 34.3 12.0 22.2 
Stage 3+: recurrent or persistent major
66.1 33.9  12.9 21.0 
Note: “No suicidal ideation” denotes HDRS item-3 score = 0; “Any suicidal ideation” denotes HDRS item-3 > 0; “Life not worth living” denotes HDRS item-3 score =
1; “Thoughts of death or Suicidal ideation” denotes HDRS item-3 score >1. HDRS = Hamilton Depression rating Scale. *Clinical stage data was missing for N = 13
cases. Chi-square testing for differences in rates of ‘no’ versus ‘any’ suicidal ideation was significantly different across diagnostic groups [χ2(3, 494) = 14.7, p< .01]
as well as illness stage [χ2(3, 481) = 9.2, p< .05].
Scott et al. BMC Psychiatry 2012, 12:234
Page 4 of 6
with the literature that is available about attempted suicide
. Help-care seeking may be occurring either directly or
through the intervention of other third parties. Certainly,
the role of parents, friends and other key persons in assist-
ing young people to come to care is evident in other data
we have reported from these service sites .
While conventional diagnostic systems draw strong
links between depressive disorders and thoughts of death
or overt suicidal ideation, it is clear in this cohort that
such phenomena do occur frequently across the diag-
nostic groupings examined. This may reflect the fact that
such diagnostic groupings are not yet well differentiated
in young persons  or the reality that thoughts of
death or overt suicidal ideation are common across most
mental disorders. Importantly, however, formal depres-
sive disorders and more severe disorders of all types
were associated with more overt suicidal ideation or be-
haviour (see Table 2).
The data set reported here has important limitations.
It relies on identification of thoughts of death or suicidal
ideation at systematic evaluation on entry to more
detailed neurobiological studies rather than at the initial
clinical assessment. While this may have biased the
study towards inclusion of more severe or persistent
cases (with consequent higher rates of thoughts of death
or suicidal ideation) it also would have favoured the in-
clusion of those young people with more persistent
thoughts of death or overt suicidal ideation. Importantly,
the demographic characteristics of this subset of sub-
jects, and the distribution of illness-stage and diagnoses,
closely match the wider cohort [10,11]. Although we did
not record respondent rates (i.e. the proportions of sub-
jects who entered our services but refused to participate
in the neurobiological studies) the current sample is rep-
resentative of a larger cohort of N =1260 subjects we
have reported on previously , who had similar levels
of functioning and psychological distress. Additionally,
the recording of suicide-related phenomena on one oc-
casion (via a Hamilton depression item) may differ from
recordings that are done on more than one occasion.
The relatively high rate of thoughts of death or overt
suicidal ideation indicates that this health-care pathway
attracts a population that is at much higher risk of sui-
cide or self-harm than young people in the general
population [4,23], who tend not have adequate contact
with specialised mental health services . While the
general goal of headspace services is to attract young
people at risk of poor long-term outcomes, these data
indicate that another specific need is readily apparent –
namely, strategies to reduce thoughts of death or overt
suicidal ideation. In conventional practice, it is often
assumed that treatment of the primary mental disorder
is the most efficient way to reduce risk of self-inflicted
harm. This study suggests that direct management of
thoughts of death, suicidal ideation or behaviour by ap-
propriate psychological or behavioural strategies may
well need to be the primary target – especially given the
fact that many of these young people may not yet have
reached conventional thresholds for initiating other
ANOVA: Analysis of variance; AUDIT: Alcohol use disorders identification test;
BPRS: Brief psychiatric rating scale; DSM: Diagnostic and statistical manual of
mental disorders; HDRS: Hamilton depression rating scale; ICD: International
classification of diseases; K10: Kessler-10; SOFAS: Social and occupational
functioning assessment scale; SPSS: Statistical package for the social sciences.
Elizabeth Scott is the Clinical Director of the headspace clinics at the Brain
and Mind Research Institute. She has received honoraria for her
contributions to professional educational seminars related to depression,
youth mental health and circadian-rhythms research. She is a member of a
national advisory board for desvenlafaxine, supported by Pfizer. She is a
participant in studies evaluating the therapeutic actions of agomelatine,
supported by Servier. Ian Hickie is supported by a National Health and
Medical Research Council Australia Fellowship (No. 464914). He was a
director of headspace: the national youth mental health foundation until
January 2012. He is the executive director of the Brain and Mind Research
Institute which operates two early-intervention youth services under contract
to headspace. He is a member of the new Australian National Mental Health
commission and was previously the CEO of beyondblue: the national
depression initiative. He has led a range of community-based and
pharmaceutical industry-supported depression awareness and education and
training programs. He has led depression and other mental health research
projects that have been supported by a variety of pharmaceutical partners.
Current investigator-initiated studies are supported by Servier and Pfizer. He
has received honoraria for his contributions to professional educational
seminars related to depression, youth mental health and circadian-rhythms
EMS, IBH and DFH prepared the initial draft manuscript. EMS, BW and IBH
supervised and verified all clinical assessments. DFH and DW conducted the
statistical analyses. EMS, DFH, SN and IBH conceived the study design. SN,
BW, AG and NG provided interpretation of the clinical data and participated
in various aspects of the study design and data collection. All authors
contributed significantly to the interpretation of the data as well as having
read and approved the final manuscript.
Professor Hickie, Dr Hermens, and A/Prof Guastella were supported by an
NHMRC Australia Fellowship awarded to Professor Hickie (No. 464914). A/Prof
Naismith was funded by an NHMRC Clinical Research Fellowship (No.
402864). This research was further supported by NHMRC Program Grant (No.
350241) and Centres of Clinical Research Excellence Grant (No. 264611), as
well as in-kind support from the Clinical Centre, Brain & Mind Research
Institute. We would also like to express our gratitude to individuals that
participated in this study.
1Clinical Research Unit, Brain & Mind Research Institute, University of Sydney,
100 Mallet Street, Camperdown, NSW 2050, Australia.2School of Medicine,
Sydney, The University of Notre Dame, 160 Oxford St, Darlinghurst 2010,
Received: 20 July 2012 Accepted: 21 December 2012
Published: 26 December 2012
Scott et al. BMC Psychiatry 2012, 12:234
Page 5 of 6
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Cite this article as: Scott et al.: Thoughts of death or suicidal ideation
are common in young people aged 12 to 30 years presenting for
mental health care. BMC Psychiatry 2012 12:234.
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Scott et al. BMC Psychiatry 2012, 12:234
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