The role of depression in the differential effect of childhood parental divorce on male and female adult offspring suicide attempt risk.
ABSTRACT In previous studies by our group, we found that female offspring of parental divorce and parental remarriage are more susceptible to suicide attempt than male offspring. In this study, we examine whether these findings remain even after controlling for offspring depression. The sample consists of respondents from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions. Multivariable regressions controlled for offspring depression, parental depression, age, race/ethnicity, income, and marital status. Our previous findings that female offspring of parental divorce and parental remarriage are more likely to report a lifetime suicide attempt than male offspring remained even after controlling for offspring depression. Findings suggest that focusing on engaging female offspring who demonstrate symptoms of depression is not sufficient to reduce suicide attempt risk in this group as many at risk individuals will remain unrecognized.
Article: Gender differences in depression.[show abstract] [hide abstract]
ABSTRACT: Depression is among the most prevalent and debilitating psychiatric disorders in the world. A striking feature of this disorder is that women are twice as likely to experience depression compared with men. Research indicates that genetic, biological and environmental factors contribute to the gender differences noted in depression. Women are more likely to suffer a greater number of and more severe stressful life events compared with men, although no gender difference has been found to explain the genetic vulnerability. As individuals with depression most frequently present to general practitioners, healthcare providers should consider screening for depression and using rigorous treatment strategies for depressed patients with comorbid medical illnesses.Women s Health 05/2006; 2(3):425-34.
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ABSTRACT: Some twin studies suggest that substance initiation and dependence are part of a complex, two-stage process and that some genetic influences are stage-specific, acting on either the transition from abstinence to initiation, or on the transition from use to dependence. However, questions remain about the two-stage model, especially for illicit drugs. Using a familial aggregation design, we tested the hypothesized two-stage model of dependence on illicit substances and alcohol in a large, nationally representative sample. Family history of drug or alcohol problems is significantly associated with initiation that does not progress to dependence (i.e., conditional initiation). Furthermore, family history of drug or alcohol problems is significantly associated with dependence even after conditioning on factors influencing initiation (i.e., conditional dependence). These results suggest that substance initiation and dependence involve at least partially distinct familial factors. The possibility that different genetic factors affect initiation and dependence has important implications for control group selection in case-control genetic association studies, and may explain some inconsistent results for drug dependence. If some genetic factors are stage-specific (i.e., not common across initiation and dependence), inclusion of abstainers in the control group may mix the genetic effects for initiation with those for transition to dependence, providing unclear results. Depending on the specific question about the nature of the genetic effect (whether on initiation, on dependence, or both), investigators designing case-control genetic association studies should carefully consider inclusion and exclusion criteria of the control group.Drug and Alcohol Dependence 02/2008; 92(1-3):258-66. · 3.14 Impact Factor
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ABSTRACT: In 1970, Guze and Robins published a meta-analysis of suicide in patients with affective illness that inferred a lifetime risk of 15%. Since then, this figure has been generalized to all depressive disorders and cited uncritically in many papers and textbooks. The authors argue for an alternative estimate of suicide risk and question the generalizability of the Guze and Robins estimate. The authors sorted studies obtained through a literature search that included data pertaining to suicide occurrence in affective illness into one of three groups: outpatients, inpatients, or suicidal inpatients. Suicide risks were calculated meta-analytically for these three groups, as well as for two previously published collections. There was a hierarchy in suicide risk among patients with affective disorders. The estimate of the lifetime prevalence of suicide in those ever hospitalized for suicidality was 8.6%. For affective disorder patients hospitalized without specification of suicidality, the lifetime risk of suicide was 4.0%. The lifetime suicide prevalence for mixed inpatient/outpatient populations was 2.2%, and for the nonaffectively ill population, it was less than 0.5%. The percentage of subjects dead due to suicide (case fatality prevalence) is a more appropriate estimate of suicide risk than the percentage of the dead who died by suicide (proportionate mortality prevalence). More important, it is well established that patients with affective disorders suffer a higher risk of suicide relative to the general population. However, no risk factor, including classification of diagnostic subtype, has been reliably shown to predict suicide. This article demonstrates a hierarchy of risk based on the intensity of the treatment setting. Given that patients with a hospitalization history, particularly when suicidal, have a much elevated suicide prevalence over both psychiatric outpatients and nonpatients, the clinical decision to hospitalize in and of itself appears to be a useful indicator of increased suicide risk.American Journal of Psychiatry 01/2001; 157(12):1925-32. · 14.72 Impact Factor
The Role of Depression in the Differential Effect of Childhood
Parental Divorce on Male and Female Adult Offspring Suicide
Dana Lizardi, PhD,* Ronald G. Thompson, PhD,* Katherine Keyes, MPH,†‡ and Deborah Hasin, PhD†‡§
Abstract: In previous studies by our group, we found that female offspring
of parental divorce and parental remarriage are more susceptible to suicide
attempt than male offspring. In this study, we examine whether these findings
remain even after controlling for offspring depression. The sample consists
of respondents from the 2001–2002 National Epidemiologic Survey on
Alcohol and Related Conditions. Multivariable regressions controlled for
offspring depression, parental depression, age, race/ethnicity, income, and
marital status. Our previous findings that female offspring of parental divorce
and parental remarriage are more likely to report a lifetime suicide attempt
than male offspring remained even after controlling for offspring depression.
Findings suggest that focusing on engaging female offspring who dem-
onstrate symptoms of depression is not sufficient to reduce suicide
attempt risk in this group as many at risk individuals will remain
Key Words: Parental divorce, adult offspring, suicide attempt, offspring
depression, parental remarriage.
(J Nerv Ment Dis 2010;198: 687–690)
offspring of divorced parents are at increased risk of suicide attempt,
even after controlling for parental depression. In a second study
(Lizardi et al., in press), we found that parental remarriage was
significantly associated with suicide attempt among female, yet not
male, offspring. Together, these studies suggest that female off-
spring of parental divorce are more susceptible to suicidality than
In these studies, however, we did not control for offspring
depression. Because it is well recognized that depression is associ-
ated with an increased risk of suicidality (Oquendo et al., 2006;
Scocco et al., 2000) and that females more often suffer from
depression than males (Nolen-Hoeksema, 2001), perhaps our previ-
ous findings of an elevated risk of suicide attempt among adult
female offspring of parental divorce reflect the differential rate of
depression among female as compared with male offspring.
In this article, whereas controlling for offspring depression,
we examine the following: (1) the effect of parental divorce on
n a previous study by our group (Lizardi et al., 2009), results
indicated that, compared with their male counterparts, female
offspring suicide attempt, (2) whether residing with the same sex
parent as compared with an opposite sex parent post parental divorce
results in differences in the risk of suicide attempt for female and
male offspring, and (3) whether parental remarriage is differentially
associated with suicide attempt for male and female offspring. This
will be the first study to examine the effect of parental divorce on the
risk of suicide attempt among adult offspring, whereas controlling
for both parental and offspring depression in a nationally represen-
tative sample using diagnostic criteria.
The sample consists of participants in the 2001–2002 Na-
tional Epidemiologic Survey on Alcohol and Related Conditions
(NESARC), a nationally representative US survey of 43,093 civilian
noninstitutionalized individuals aged 18 and older, interviewed in
person. Field methods of the survey are fully described elsewhere
(Grant et al., 2003) as are details regarding sociodemographic
characteristics of the sample (Lizardi et al., in press). The research
protocol, including informed consent procedures, received full eth-
ical review and approval from the US Census Bureau and US Office
of Management and Budget.
The Alcohol Use Disorder and Associated Disabilities Inter-
view Schedule (AUDADIS; Grant et al., 2003) was administered to
all NESARC participants. The AUDADIS is a structured diagnostic
interview specifically designed for lay interviewers.
Assessment of Offspring Depression
Offspring depression was assessed in a module of the
AUDADIS that focused on questions regarding low mood (see
Heiman et al. (2008) for details). Subjects were asked whether they
had ever experienced a time in their lives when they felt sad, blue,
depressed, or down most of the time for at least 2 weeks. They were
then asked whether they ever had a time, lasting at least 2 weeks, when
they did not care about the things that they usually cared about, or did
not enjoy the things they usually enjoyed. If respondents answered
affirmatively to either of these questions, they were then asked fol-
low-up questions regarding the details of their experience during the
time when their mood was low including, duration, frequency, timing,
as anhedonia, sleep, appetite, and concentration.
Assessment of Suicide Attempt
Lifetime suicide attempt was assessed among those respondents
who screened into the major depression section of the survey. Individ-
they reported feeling sad, blue, depressed, or down most of the time for
at least 2 weeks, or feeling anhedonic for at least 2 weeks ever in their
lifetime (N ? 13,753). Of these, a total of 1074 respondents reported
attempting suicide in their lifetime. Individuals who screened into the
depression section but did not report a suicide attempt history, as well
*Graduate School of Social Work, Columbia University, New York, NY; †New
York State Psychiatric Institute, New York, NY; ‡Department of Epidemiol-
ogy, Mailman School of Public Health, Columbia University, New York, NY;
and §Department of Psychiatry, College of Physicians and Surgeons, Colum-
bia University, New York, NY.
Supported by K05 AA 014223 and R01AA13654 (to D.H.), a fellowship from the
National Institute of Mental Health (T32 MH013043–36; to K.K.), and the
New York State Psychiatric Institute.
No authors have any relevant financial interests.
Send reprint requests to Dana Lizardi, PhD, School of Social Work, Columbia
University, 1255 Amsterdam Ave, New York, NY 10027. E-mail:
Copyright © 2010 by Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 198, Number 9, September 2010www.jonmd.com | 687
as those who did not screen into the depression section, constituted the
reference group for lifetime suicide attempt. Although it is possible that
this screening method resulted in the exclusion of individuals with a
history of suicide attempt who did not experience depression, suicide
attempts are most often associated with mood disorders as compared
with other psychiatric disorders (Bostwick and Pankratz, 2000). There-
fore, it is likely that the large majority of persons at risk for attempting
suicide were included. Furthermore, to examine the effects that limiting
inquiries regarding suicide attempt history to those who reported 2
compared our data with another source of data, the National Longitu-
dinal Alcohol Epidemiologic Survey (NLAES) survey (Grant, 1997).
Similar to the NESARC, the US Bureau of the Census administered the
NLAES to a nationally representative sample of 42,862 respondents in
the contiguous US and District of Columbia in 1991–1992 and used a
similar design and interview (Grant, 1997). The NLAES examined
lifetime risk of suicidal behavior in all respondents. Analyses of these
data showed that of the respondents who did not screen into the
attempt. Thus, this limitation in the NESARC was not likely to have a
large effect on the results.
Assessment of Childhood Parental Divorce and Remarriage
Childhood experience of parental divorce was assessed with
the question: “Did your ?biological/adoptive? parents get divorced or
permanently stop living together before you were 18?” To assess for
parental remarriage, a follow-up question was asked which ascer-
tained whether the respondent lived with a stepparent before the age
of 18. Because the NESARC does not ask respondents the age at
which they attempted suicide, to better establish that parental di-
vorce preceded a suicide attempt, individuals whose parents di-
vorced when the respondent was between the ages of 13 to 17 were
excluded from the analysis (N ? 1556) as suicide attempt among
prepubertal youth is extremely rare (National Center for Health
Statistics, 2000). To more clearly understand the effect of residing
primarily with a parent of the same or opposite sex post parental
divorce, only respondents primarily living mother or father were
considered (N ? 4895).
The prevalence of offspring depression by gender of offspring
was calculated with cross-tabulations. The effects of offspring de-
pression on adult offspring suicide attempt by gender was calculated
using a logistic regression model, first unadjusted and then adjusted
for sociodemographic and clinical characteristics. Specifically,
based on baseline analyses that showed associations with offspring
suicide attempt, the following demographic variables were used as
controls in multivariable regressions: age (18–24, 25–44, 45–64,
65?), race/ethnicity (non-Hispanic White, non-Hispanic Black, His-
panic, and other), family income (?$20,000, $20–34,999, $35–
69,999, $70,000?), and marital status (never married, widowed/
Odds ratios (ORs) and 95% confidence intervals (CIs) were
derived from the beta estimates in the logistic regression models.
F-tests were used to estimate the statistical significance of the
inclusion of interaction terms in the model, and ORs and confidence
interval estimates were calculated using the beta estimate for the
interaction. To adjust for the complex sample characteristics of the
NESARC, all analyses were conducted using SUDAAN (Research
Triangle Institute, 2004). This software adopts Taylor series linear-
ization to take into account the design effects of the NESARC.
Controlling for offspring depression had minimal effect on
the differential odds of suicide attempt found between female and
male offspring of parental divorce and remarriage found in previous
studies. Table 1 reports the main and interaction effects of parental
divorce and offspring gender on lifetime suicide attempt, adjusting
Adjusted and Unadjusted Odds Ratios for Parental Divorce, Parent Gender, and Parental Remarriage
Experience With Parents
% (SE) OR (95% CI)a
AOR (95% CI)
aAdjusted for age, sex, race/ethnicity, family income, marital status, parental depression, and offspring depression.
bInteraction of gender and divorce trended toward significance in unadjusted (t ? 1.80, p ? 0.08) and adjusted models (t ? 1.54, p ? 0.13).
cInteraction of custodial parent and offspring gender not significant in unadjusted (t ? 1.65, p ? 0.10) model, significant at a trend level in adjusted model (t ? 1.95, p ? 0.06).
dInteraction of lived with stepparent and offspring gender not significant in unadjusted (t ? 0.86, p ? 0.35) model, significant at a trend level in adjusted model (t ? 0.60, p ? 0.37).
*p ? 0.01.
**p ? 0.05.
SE indicates standard error; CI, confidence interval; AOR, adjusted odds ratio.
Lizardi et al.
The Journal of Nervous and Mental Disease • Volume 198, Number 9, September 2010
688 | www.jonmd.com
© 2010 Lippincott Williams & Wilkins
for offspring depression. Females who experienced parental divorce
were 1.46 times as likely (95% CI: 1.14–1.88) to report a suicide
attempt than those who did not experience parental divorce. This
association was not found among male offspring. In addition, there
was a trend toward a significant interaction between parental divorce
and gender in predicting lifetime suicide attempt (t ? 2.40, p ?
0.13), providing preliminarily evidence that the effect of childhood
parental divorce on the odds of offspring suicide attempt may vary
between male and female offspring.
The main and interaction effects offspring gender and custo-
dial parent gender on lifetime suicide attempt, adjusting for off-
spring depression are also presented in Table 1. The prevalence of
suicide attempt among women who lived with their mothers was
4.7% (standard error ?SE? ? 0.5), compared with 9.4% (SE ? 1.7)
among women who lived with their fathers. In adjusted logistic
regression, women who lived with their fathers after parental di-
vorce were significantly more likely to make suicide attempts
(OR ? 2.87, 95% CI: 1.63–5.04) compared with men who lived
with their fathers. Women who lived with their fathers were signif-
icantly more likely to report a suicide attempt than women who lived
with their mothers (OR ? 2.10, 95% CI: 1.29–3.43). There was a
trend toward significance in the interaction between gender of the
parent and gender of the respondent in predicting lifetime suicide
attempt (t ? 3.80, p ? 0.06).
The prevalence of suicide attempt by offspring gender and
parental remarriage is also presented in Table 1. Among women
whose parent remarried, the prevalence of suicide attempt was 6.9%
(SE ? 0.8) compared with 4.1% (SE ? 0.6) among women whose
parent did not remarry. In adjusted logistic regression, women
whose parent remarried were more likely to report suicide attempt
than men whose parent remarried (OR ? 1.98, 95% CI: 1.16–3.37).
In addition, women whose parent remarried were significantly more
likely to report a lifetime suicide attempt than women whose parent
did not remarry (OR ? 1.54, 95% CI: 1.04–2.28). Parental remar-
riage was not significantly associated with suicide attempt among
men. Interaction of parental remarriage and offspring gender was not
significant in adjusted models (t ? 0.94, p ? 0.34).
Consistent with prior studies conducted by our group, the
results of this study found increased odds of suicidality among
female as compared with male offspring, even after controlling for
offspring depression. These findings reinforce that female offspring
of parental divorce may be at greater risk for suicidality than once
considered and risk assessment targeting this group should be
integrated into standard clinical practice.
In our study, female offspring of parental divorce were more
likely to report a lifetime suicide attempt than male offspring, even after
controlling for depression. It is suggested that women who face nega-
tive events, such as parental divorce, are faster than men at retrieving
memories of other negative events, experiencing these memories and
their accompanying negative feelings in greater detail and to greater
degrees (Appleby et al., 1999). Males, on the other hand, have been
found to be more dismissive of negative emotions (Koestner et al.,
1991; Scharfe and Bartholomew, 1994). Perhaps, the manner in which
females process and experience negative events, independent of depres-
sion, contributes to why female offspring of divorce are at greater risk
of suicide attempt than male offspring.
In this study, we found that female offspring who experience
parental remarriage have greater odds of suicide attempt than those
who do not. This is consistent with prior research that indicates that
repeated exposure to negative situations where one has little control,
such as parental remarriage, increases feelings of helplessness and
depression (Milkulincer, 1994; Peterson et al., 1993). Women are
more likely than men to experience situations where they are made
to feel helpless, such as through sexual abuse and single parent
situations, and, thus are more likely to develop a sense that they are
not in control of their environments. This increases the likelihood
depression and in turn, the risk of suicide attempt (Ehnvall et al.,
2008; Nolen-Hoeksema, 2001).
Methodological limitations need to be considered. First, the
NESARC is based on respondent self-report that can be affected by
recall bias and social desirability. However, most large epidemio-
logical studies use self-report measures and the NESARC used a
carefully structured interview to assess aspects of clinical history
that agreed well with psychiatrist evaluations. Second, because
childhood parental divorce and permanent separation were covered
in a combined question, any difference in effects of legal divorce
compared with permanent separation cannot be determined.
Whereas any differences may be small, especially when the event
occurs during early childhood when respondents did not understand
the legal difference, the issue should be addressed in future studies.
Third, the NESARC did not ask respondents for the date of their
suicide attempts. Therefore, temporality of suicide attempt in rela-
tion to parental divorce cannot be definitively established. However,
to address this, we included only respondents whose parents di-
vorced before they were 13 as few suicide attempts occur before that
age. Fourth, only subjects who screened into the major depression
section of the interview (by reporting ever experiencing at least 2
weeks of depression or anhedonia) were asked about suicidality.
However, as mentioned, this limitation was likely to result in fewer
than 1% of individuals with a history of suicide attempt being
excluded from the study. Therefore, this is a minor limitation.
This study also has notable strengths. First, the study used a
large, nationally representative sample. Second, assessments were
based on DSM-IV diagnostic criteria. Third, the research builds on
prior findings concerning parental divorce and offspring suicide
attempt by examining the differential effect of childhood parental
divorce on male and female adult offspring.
Female offspring experience increased odds of suicide at-
tempt as compared with male offspring, even after controlling for
offspring depression. Suicide prevention efforts should aim to en-
gage female offspring of parental divorce, a group formerly believed
to be at low risk for suicide attempt. Such targeted efforts may lead
to a decrease in suicide rates as individuals previously unrecognized
to be at risk will finally receive the attention they require.
The authors thank Valerie Richmond, MA, for editorial as-
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