Content uploaded by Anne Mari Sund
Author content
All content in this area was uploaded by Anne Mari Sund on Apr 18, 2016
Content may be subject to copyright.
ABSTR ACT
Background & Aim: The current study examined non-attempters,
attempters and repeaters of suicide attempts in relation to stressful
life events and their levels of depression symptoms in an extracted
subset that was followed up from adolescence into early adulthood.
Did repeaters consistently report more stressful events and depres-
sion than single at tempters and non-at tempters? If yes, was this
increase of events located in the family or at school or in the domain
of self and friends? Method: A representative sample of high school
students (T1, n = 2464, mean age = 13.7 years, 50.8% female,
88.3% participation) was re-assessed with the same questionnaire
after a year (T2Q). High scorers of depression on the Mood and
Feelings Questionnaire (MFQ) were matched for gender and age with
low-and-middle scorers and assessed diagnostically by face-to-face
interviews at T2I (n = 345, 94% participation). The inter viewed subset
was reassessed again 5 years later (T3) with the same question-
naire (n = 252, mean age = 20.0 years, 73% participation) and by
telephone inter views. Stressful events were detected from a list of
three domains. Results: Repeaters of suicide attempts reported more
stressful events and were consistently more depressed. Differences
in domains of stressful life events were also obser ved.
Conclusion: Interventions including healthy coping in relation to
stressful events and depression among adolescents may prevent
suicide. Key words: longitudinal, K-SADS, adolescents, young adults.
Bakgrunn og målsetning: I denne studien ble tre grupper ungdom-
mer med høye depresjonsskårer undersøkt: noen som aldri hadde
forsøkt å ta livet sitt, en gruppe bestående av personer som hadde
forsøkt en enkelt gang og en gruppe som hadde forsøk t flere ganger.
Dette ble sett i forhold til antall og type belastende livshendelser
og depresjonsgrad. Ungdommene ble fulgt fra tidlige tenår frem til
starten av deres voksenliv. Spørsmålene som studien ville belyse,
var om ungdommer med gjentatte selvmordsforsøk rapporterte
flere belastende livshendelser og/eller var mer deprimerte enn de
som hadde forsøk t bare en gang eller ikke i det hele tatt. Hvis det
skulle være vise seg å være tilfellet, ville man se nærmere på hvilke
livsområder hvor det kunne finnes øk t forekomst av belastende
livshendelser – innen familien, skolen eller selv og venner. Metode:
I utgangspunktet undersøkte man et st ørre antall skoleelever (T1;
n=2464; gj.snittsalder = 13.7 år; 50.8% kvinner; 88.3% deltakelse).
De ble igjen undersøkt ett år senere med samme spørreskjema (T2).
Elever som da hadde høye depresjonsskårer på Mood and Feelings
Questionnaire (MFQ) ble matchet (2:1) for kjønn og alder med andre
elever som hadde lave eller middels depresjonsskårer; de ble videre
vurder t med et diagnostisk intervju ansikt til ansikt (T2; n=345; 94%
deltakelse). Dette selekterte utvalget ble på ny tt vurdert 5 år senere
(T3) med samme spørreskjema (n =252; gj.snittsalder = 20.0; 73%
deltakelse) og med telefonintervju hvor dessuten belastende livshen-
delser på tre livsområder ble kartlagt.Funn: Både de som hadde
begått selvmordsforsøk en gang og de med gjentatte selvmords-
forsøk rappor terte på alle tidspunk ter langt flere belastende livshen-
delser enn andre ungdommer, de var dessuten gjennomgående
dypere deprimerte enn ø vrige. Det ble også funnet forskjeller i hvilke
livsområder hvor de var mest belastet. Konklusjoner: Hjelpetiltak
som stimulerer unge mennesker til bedre mestring av belastende
livshendelser og som er deprimer te, kan trolig virke forebygge mot
selvmord innen disse aldersgruppene.
Introduction
In adolescence, a past suicide attempt has been documen-
ted to be the most powerful predictor of a later attempt or
completed suicide even when adjusting for psychiatric dis-
orders (Nrugham, Larsson & Sund, 2008; Bridge, Goldstein
& Brent, 2006; Lewinsohn, Rhode, Seeley & Baldwin, 2001).
Among female adolescents, a prior suicide attempt has
been found to be a stronger predictor of completed suicide
(Grøholt, Ekeberg, Wichstrøm & Haldorsen, 1999). Prospec-
tive studies focussing on repeated suicide attempts have
tended to use clinical samples (Sheikholeslami, Kani, Kani
& Ghafelebashi, 2009; Hulten et al, 2001). Their ndings
about repeate rs report hig her levels of depression , hopeless-
ness, higher levels of intent and impulsivity, but also the
use of more violent suicide methods such as hanging and
jumping from high places; in addition, they report more
negative life events as well
as limited social support.
Adult clinical samples have
also revealed differences
between single-attempters
and repeaters. The adult
repeaters reported more
stressful events (Joiner et
al. 2007), they used poorer
social problem solving skills
and demonstrated increased
levels of psychopathology, of depression in particular
(Forman, Berk, Henriques, Brown & Beck, 2004; Rudd,
Joiner & Rajab, 1996).
The relationship between stressful events and suicide
attempts across the lifespan has been reported in retrospe-
ctive clin ical studies (Gladstone et al. 2004; Forman et al.
2004), in prospective longitudinal community-based stu-
dies (Johnson et al. 2002), in retrospective cross-sectional
studies (Joiner et al, 2007), in rev iews (Bridge et al. 2006;
Gould, Greenberg, Velting, Shaffer, 2003; King et al. 2001;
Paykel, 2001), and in psychological autopsies of adoles-
cent suicides (Portzky, Audenaert & van Heeringen, 2005;
Gould, Fischer, Parides, Flory & Shaffer, 1996). Among Nor-
wegian adolescents, the non-intact biological parental unit
has been found to be an associate of attempted or comple-
Prospective
studies focussing
on repeated suicide
attempts have
tended to use
clinical samples
suicidologi nr 2/2015 43
Attempted suicide and repeated attempts from adolescence to early adulthood: depression and stressful events
ted suicide (Nrugham, Larsson & Sund, 2008; Wichstrøm,
2000; Grøholt, Ekeberg, Wichstrøm & Haldorsen, 1998;
Grøholt, Ekeberg, Wichstrøm & Haldorsen, 1997). However,
stressful life events alone did not predict suicidality among
patients with MDD in the last 12 months; in a sample aged
between 7 to 17 years (Myers et al. 1991); the same was the
case for outpatients aged 14 to 72 years (Mann, Waternaux,
Haas & Malone, 1999).
An additional matter to be considered is that clinical
and non-clinical samples may not have similar risk factors
(Agerbo, 2007). Apart from these gaps in our knowled-
ge, it is not known whether specic domains of stressful
life events, such as self and
friends, school, or family,
tend to be associated w ith
suicidal behaviour. Such
knowledge can aid clinici-
ans mould their interven-
tions to reduce suicidal be-
haviour among adolescents
and young adults.
The present study compa-
red the severity of depres-
sion symptom scores in
relation to three domains
of stressful life events bet-
ween three groups: ‘non-
attempters’, ‘attempters’ and
‘repeaters’. We sought answers to the following questions:
Did repeaters differ from single attempters and non-at-
tempters on the severity of depression symptom scores and
in the exposure to the domain of stressful events as they
grew up? Did repeaters report persistent and more depres-
sive symptoms than the others? Did repeaters consistently
report more stressful events than single attempters and
non-attempters? If yes, was this increase of events located
in the family or at school or the domain of self and friends?
Method
Design and participants
A prospective design was used with a sample of predomi-
nantly depressed high school students followed up into
early adulthood. This was done in two ways: longitudinal-
ly, within the groups, to cover the developmental aspect,
and also, cross-sectionally between the three groups. The
participants of this research project on depression titled
‘‘Youth and Mental Health’’, were derived from a non-cli-
nical sample of adolescents of 8th and 9th classes (13 to 14
year olds) from two counties in Central Norway. The total
population numbered 9292 in 1998. A clustered sampling
technique resulted in a representative sample of 2792 stu-
dents from 22 schools. L arsson & Sund (2008) have provi-
ded a detailed description of the procedure and sample. All
assessments were approved by the Regional Committee for
Medical Research Ethics, Central Norway. Informed con-
sent, based on standards prescribed by The Norwegian
Data Inspectorate, was obtained from the participants.
Local school authorities, including the school boards,
approved the study at T1 and T2.
Assessment time-points
T1: A questionnaire with an embedded screening seg-
ment for depression, the Mood and Feelings Questionnaire
(MFQ, described below), was completed at school. N = 2464,
mean age = 13.7 (SD = 0.5) years, 88.3% participation, 50.8%
female.
T2: The questionnaire was again completed at school by the
same sample a year later. N = 2432, mean age = 14.9 (SD =
0.5) years, 86.7% participation, 50.3% female.
Subset. Those with MFQ scores above 25 were dened as
high scorers. One adolescent was selected at random from
the low (0-6) or middle scorers (7-24) and matched for age
and gender with every two high-scorers. Of the 364 ado-
lescents thus selected, 345 were diagnostically intervie-
wed face-to-face at school by one of six trained intervie-
wers. The high-scorers numbered 225, and the comparison
group, 120. The participation rate was 94.7% with 72.5%
females.
T3: Adolescents who had been interviewed and had con-
sented to be invited again at T2 were contacted at T3 about
5 years later (n = 337). Those willing to be inv ited (n = 303)
were sent questionnaires by mail and interviewed by
telephone. The T3 questionnaire participation rate was
73%, n = 252, mean age = 20.0 (SD = 0.6) years, 77% females.
The analyses of this study were limited to these 252 young
adults. More details provided in Nrugham, Holen & Sund,
2010.
Measures
Interview. The Kiddie – Schedule for Affective Disorders
and Schizophrenia – Present and Lifetime version (K-SADS-
PL) is a well-established, semi-structured diagnostic inter-
view (Kaufman et al. 1997). It assesses current and past
episodes of A xis I psychopathology according to the DSM-
III-R & IV-TR criteria in children and adolescents. Probes
and objective criteria for clinical thresholds are given in
the screening and supplement sections. For nearly 80% of
the adolescents, at least one
of their parental gures was
separately interviewed face-
to-face as an additional
informant at T2. The inter-
viewer’s summary scores
were based on all available
interview information.
Blind interv iews were
conducted by experienced
clinicians trained both in
assessing psychopathology and in the use of K-SADS. The
average time between completion of the questionnaire
and the interv iew, was 20 days at T2, and at T3, 21 days.
Inter-Rater Reliability (IRR) using taped recordings, be-
fore interview ing was good with Cohen’s kappa of 0.71 at
T2 for all screening symptoms and affective supplements,
and with a kappa at 0.70 for all screening and supplement
symptoms at T3. Interview integrity was maintained at T2
and T3 with an average kappa of 0.83 at T2, and 0.80 at T3.
The IR Rs were obtained with co-author AMS, an experien-
ced, practising and academic psychiatrist (see Nrugham,
Attempted suicide and repeated attempts from adolescence to early adulthood: depression and stressful events
The T3 questionnai-
re participation rate
was 73%, n = 252,
mean age = 20.0
(SD = 0.6) years,
77 % females
Do repeaters differ
from single attemp-
ters and non-attem-
pters on the seve-
rity of depression
symptom scores
and in the exposure
to the domain of
stressful events as
they grew up?
44 suicidologi nr 2/2015
Attempted suicide and repeated attempts from adolescence to early adulthood: depression and stressful events
Figure 1 Flow of participants in the Youth and Mental Health Study over the three timeframes from T1 to T3.
T1= 1998; T2 = 1999/200 0, T3 = 2004/2005.
Total population
N=9292
Invited to T1
assessment
N=2792
Participants at T1
N=246 4
Participants at T2
N=243 2
MF Q>25
N=231
Invited to Interview
N=228
Interviewed
N=220
MFQ<26 + 1
unknown
N=2190
Invited to interview
N=13 6
Interviewed
N=12 5
Interview sample
T2
N=345
Questionnaire sample
T3
N=252
Interview sample
T3
N=242
Refusals
N=8
Refusals
N=11
Refusal T3
N = 34
Refusals
N=328
Non-
participants
N=534
suicidologi nr 2/2015 45
Holen & Sund, 2010, for further details). The interview was
used to extract a single variable: attempted suicide (descri-
bed below).
Questionnaire. The questionnaire was a compilation of se-
veral segments. Not living with both biological parents by
T2 was derived from the information about the civil status
of the parents and the adolescent’s residence by T2.
Depression was explo-
red by the 34 items of the
MFQ – Mood and Feelings
Questionnaire covering the
DSM–III-R criteria for ma-
jor depression (Angold et
al. 1989). This instrument
has been used to identify
respondents in a diagnostic
interview; it was found age
sensitive among girls both
in a non-clinical sample (Goodyer & Cooper, 1993) and in
several clinical samples (Kent, Vostanis & Feehan, 1997;
Wood, Kroll, Moore & Harrington, 1995). The MFQ consists
of descriptive phrases about the participant’s feelings or
behaviour in the last two weeks. Each item was rated on
a 0-2 scale. The total score ranges from 0 to 68. The mean
MFQ score of the original sample was 10.6 (SD = 9.5) at T1
(Sund et al., 2001). Psychometric properties of the MFQ
were excellent with the original sample (Sund et al. 2001).
Stressful Events were assessed by a list of 33 items at
T1 and T2, with 47 items at T3. The list drew on existing
instruments: Coddington’s (1972) Life Event Scale, Col-
ton’s (1985) Children’s Own Perceptions and Experiences
of Stressors (COPES), Swearingen & Cohen’s (1985) Junior
High School Life Events. It also included some additional
self-made items based on stressors regarded as salient in
early adolescence (see Sund et al. 2003, for details).
Furthermore, the stressful events were grouped into
three domains: school, family, self and friends. Examples:
school event: ‘teacher has ridiculed you in front of the
class’; family event: ‘family member seriously ill or inju-
red’; self & friends’ event: ‘I have been a victim of sexual
harassment’ or ‘I have been a victim of a criminal act’ and
‘A friend has serious problems’. The response options were
‘yes’ and ‘no’. The time span covered the past 12 months.
The total score ranged between 0-33 at T2 and 0-47 at T3.
The number of endorsed stressful events in each domain
was summed up for the analyses. The language of the qu-
estionnaire was made age-appropriate at T3 for the added
fourteen items covering such as romantic relationships,
pregnancy and abortion.
The non-participants (n = 93) at T3 were more often ma-
les [ (1) = 5.7, p < 0.01] and victims of criminal acts [ (1) =
6.9, p < 0.008] by T2, and the females were more likely to
have experienced sexual harassment [ (1) = 4.64, p < 0.03]
by age 15. At T2, a signicant difference between the mean
depression scores of the participants and the non-partici-
pants was not obser ved.
Attempted suicide status. This variable with three groups as
described below was constructed by using positive respon-
ses, either from the interview or the questionnaire. Acts of
self-harm, as differentiated from suicidal acts by either the
interviewer or the respondent, were excluded. Only those
suicidal acts were included that reached a clinical thres-
hold as assessed by the interviewers. The questions about
suicidal behaviour were in the screening probes for depres-
sion in K-SADS. A positive and clinical threshold response
to the question “Have you ever (or since the last interview)
tried to k ill yourself or done something which could have
killed you?’’ was dened as a suicidal act. The item of the
questionnaire was taken from the ‘Young in Norway’ study
(Wichstrøm, 2000), a previous national survey: ‘‘Have you
ever tried to commit suicide?’’ The response options were:
‘‘No, never’’; ‘‘Yes, once’’; ‘‘Yes, several times’’.
From the information thus pooled, th ree groups were
derived: (a) non-attempters (n = 177, females = 137), those
who had never reported any suicidal act; (b) attempters (n
= 52, females = 37), those who reported one suicidal act at
any one assessment point, T1, T2, or T3 and, (c) repeaters
(n = 23, females = 20), those who reported at least one sui-
cidal act by T2 and, had tried again between T2-T3. This
requirement of a suicide attempt at both assessments was
not without cost. The advantage was that consistency in
suicidal behaviour across the period of adolescence was
ensured. The disadvantage was that those who on ly had
repeated within each assessment time period, would be
counted as attempters, not repeaters. However, as the focus
of the present study was on the longitudinal perspective,
the trade-off was accepted in favour of temporal stabilit y
across adolescence.
Statistical analyses
Missing data on continuous variables were few and treated
with Expectation Maximization, or the Regression method
as per the indicators given by Little’s Missing Completely at
Random chi-squared test value’s signicance (Tabachnick
& Fidell, 2006). Details have been provided earlier (Nrug-
ham, L arsson, Sund, 2008). Due to cluster sampling, the
probability of intra-school correlation coefcient for de-
pression symptom scores at T2 was estimated and found
to be 0.013. The total variance attributable to differences
between schools was therefore rather small, and indicated
that it was safe to proceed with the usual variance and re-
gression analyses (Norusis,
2004).
Repeated measures AN-
OVA was used to test for
signicance of the longitu-
dinal differences between
depression sy mptoms a nd t he
domains of stressful events
(Tabachnick & Fidell, 2006;
Field, 2005). Mauchly’s test
indicated that the assumption of sphericity had been vio-
lated except for stressful events in the family and school
domains. The degrees of freedom were corrected by using
Greenhouse-Geisser estimates of sphericity for relevant
variables. Corrected F-statistics and partial eta-squared
values as effect size are reported. Bonferroni corrections
were applied to control Type I error rate. One-way ANOVA
tests were used to check for signicant cross-sectional
differences between groups. Contrasts were planned with
the t-statistic, and effect sizes (r) were calculated for signi-
cant t values. Corresponding values of Cohen’s d are repor-
ted here as effect size indicators. Post hoc tests were used to
conrm the contrasts. Due to unequal sample sizes, Gabriel’s
Acts of self-harm,
as differentiated
from suicidal acts
by either the
interviewer or
the respondent,
were excluded
This requirement
of a suicide
attempt at both
assessments was
not without cost
46 suicidologi nr 2/2015
Attempted suicide and repeated attempts from adolescence to early adulthood: depression and stressful events
Table 1 Suicide attempt status, depression and stressful life events at ages 14 (T1), 15(T2) and 20(T3).
Comparing non-attempters, suicide attempters and repeaters with regard to their levels of depression and their number of reported stressful
life events within three domains (School, Family, and Self & friends) in a school sample (n = 252) assessed at T1 (age 14), at T2 (age 15),
and from which a subset of mainly high scorers on depression (measured by the Mood and Feelings Questionnaire) was followed up at T3
(age 20). ANOVA results presented in F-values.
Variables
Non-attempters
(n = 177)
Attempters
(n = 52)
Repeaters
(n = 23)
M (SD) M (SD) M (SD) F value df2 t-statistic (df) Coh en’s d
Depression scores
Depression T1 15.2 (10. 8) 22.3 (13.3) 26 .8 ( 11. 6 ) 15.4*** 249 a 3.8 (249)***
b 4.5 (249)***
0.5
1.0
Depression T2§23.0 (13.9) 3 4. 0 (12 .5 ) 35.1(12 . 2) 20.4*** 55.4 a 5.4 (91.5)***
b 4.3 (29.9)***
0.8
0.9
Stressful Life Events (SLE) in School, Family, Self & friends
T1
SLEs – School 8.7 (1.5) 8. 9 (1. 4) 9.0 (1.4) 0.9 249
SLEs – Family 21. 6 (2 .1) 22.5 (2.5) 23 .1 (1. 9) 6.9*** 249 a 3.5 (249)***
b 3.0 (24 9)**
0.3
0.7
SLEs – Self & friends 7.6 (0.8) 7.9 (1.1) 8.1 (0.8) 4.4* 249 a 2.3 ( 249)*
b 2.2 (249)*
0.3
0.6
T2
SLEs – School 1.9 (1.5 ) 3.1 (1.6 ) 3 . 4 (1.1) 18.3*** 249 a 4.7 (249)***
b 4.4 (249)***
0.7
1.1
SLEs – Family§2.8 (2.3) 4.6(3.3) 4.6 (2.4) 10.8*** 50.6 b 3.4 (27. 7 )** 0.7
SLEs – Self & friends 0. 9 (1.1) 1. 5 (1.2 ) 1.7 (1. 3) 7.8*** 249 a 3.1 (249)***
b 2.8 (249)***
0.5
0.6
T3
SLEs – School 5.7 (0.9) 6.0 (1.0) 5.9 (1.2) 1.8 249
SLEs – Family 24.2 (2.0) 24.8 (2.0) 24. 8 (2.1) 2.6 249
SLEs – Self & friends§2 2 .1 ( 1. 9) 23.0 (2.7) 24.0 (2.7) 7.4*** 47.6 a 2.3 (66.8)*
b 3.2 (24.9)**
0.3
0.8
§ = Welch’s F sta tistic repor ted due to violat ion of homogen eity of varian ces. Degrees o f freedom (1) = 2, unless o therwise sp ecified. * = p < 0.05 , ** = p < 0.01, *** = p < 0.001.
a = betwee n non-attem pters and atte mpters; b = betw een non-att empters and rep eaters.
test was used (Field, 2005). Analyses were one-tailed as per
the hypothesis, and the α-level was set to p ‹ 0.05.
Results
Non-attempters, attempters and repeaters – longitudinal
overview
Signicant differences were seen within each of the
three groups: between ages 14, 15 and 20, in the domain of
stressful events at school [F (3.9, 494.9) = 5.8, p < 0.0005,
η2 = .04] and in the domain of stressful events related to
self and friends [F (2.9, 367.2) = 3.4, p < 0.05, η2 = .02]. Post
hoc tests with Bonferroni corrections revealed signicant
differences for all variables between non-attempters as
compared to single attempters and repeaters.
The repeaters (n = 19, 82.6%) were signicantly more li-
kely to be not living with both biological parents at age 15
than the attempters (n = 22, 42.3%) and the non-attempters
(n = 51, 28.8%), = 10.9, p < 0.01. Age differences between
these three groups were not statistically signicant. Table
1 displays the temporal comparisons of the depression sco-
res and stressful life events among the non-attempters, at-
tempters and repeaters. All three groups had higher mean
depression scores at age 15 than at age 14. The attempters
and repeaters reported scores indicating major depression.
The actual number of stressful events decreased at age 15
for all three groups in the three stress domains. However,
signicant differences between the groups were seen in
all domains, with attempters and repeaters reporting more
events than non-attempters. At age 20, when the number
of stressful events within the family and, with self and fri-
ends were at the highest for all three groups, family-rela-
ted events remained at the same level in all the groups, as
seen in Table 1.
suicidologi nr 2/2015 47
Attempted suicide and repeated attempts from adolescence to early adulthood: depression and stressful events
Differences between non-attempters, attempters and repeaters
Contrasts were set up to detect the source of the group
differences revealed above. The last two columns in Table 1
provide an over view of the signicant ndings with Cohen’s
d values of effect size. The post hoc tests conrmed all the
differences.
Discussion
The main new ndings of the present study were two:
(a) repeaters of suicide attempts reported more stressful
events and were consistently more depressed, (b) stress-
ful events within the family, and within the domain of self
and friends peaked at age 20. The stressful events at school
were highest at 14 years, across all three groups.
Wilson et al. (1995) suggested that suicidal adolescents
may have difculties in seeing their personal contributions
to stressful situations which in turn could lead to a redu-
ction in the use of healthy coping. Their suggestion may
be useful in the interpretation of our ndings as applied
to attempters and repeaters. Difculties emerging in sui-
cidal adolescents may be amplied and stabilised among
repeaters.
Severity of depression symptoms and domain of stressful events
Non-attempters, attempters and repeaters had higher
mean depression scores at age 15 than at age 14, which is
in line with earlier reports about high school adolescents
(Lewinsohn et al. 2001; 1993). Repeaters were least likely
to be living with both biological parents by the age of 15;
they were followed by attempters, both ndings are in line
with earlier reports (Wagner, Cole & Schwartzman, 1995;
Wichstrøm, 2000). The stressful events of repeaters ori-
ginated mostly in their
families by age 14, spread
into their schools by age 15,
and moved into the domain
of self and friends by age
20. The level of depression
symptom scores reported
by repeaters was higher and
more consistent than the
others, w ith the exception
of attempters at age 15. Our
ndings proled the repea-
ters as not only consistently
reporting more stressful
events in all areas, but also,
they had less internal and
external supports than the other two groups; the same
was found for adults (Forman et al. 2004; Rudd et al. 1996).
Attempters and repeaters appeared to be more similar than
dissimilar. Together, they differed sharply from the non-
attempters. The suicidal risk of individuals is remarkably
stable across adolescence into adulthood (Nrugham et al.
2008; Lew insohn et al. 2001).
The stress-diathesis model of behaviour in adult psychia-
tric patients proposes that the risks for suicidal acts are not
merely determined by their illness but also by a diathesis, a
pre-existing psychological vulnerability (Mann et al.1999).
To a certain extent, our ndings were able to extend this
model to adolescents, as the repeaters consistently repor-
ted more stressful events in all domains, and also, as they
had less internal support than the other two groups. This
nding is in line with reports on adult samples (Forman et
al. 2004; Rudd et al. 1996). Thus we observe that adoles-
cents were alike and yet, different from adults in the rela-
tionships between attempted suicide, depression symptom
scores and stressful events.
Limitations and strengths
Several limitations of the present study merit considerati-
on. The small sample of repeaters was a result of the low
frequency of attempted suicide. Caution is imposed on the
interpretation of the ndings due to reduced power to de-
tect otherw ise signicant differences, increased chance of
Type II errors, and increased number of stressful events
introduced at T3. It must also be considered that more
than two-thirds of the subset was of the female gender.
This sample resembles an
outpatient population more
than any other due to the
over-sampling of depressed
adolescents at age 15 and the
clinical thresholds of suicide
attempts used in the inter-
vie w.
However, the study also
has several substantial
strengths: a longitudinal
design placed at a crucial
developmental life phase of a large population-based sam-
ple pool from which the subset was drawn, the choice of
measures for depression symptoms, stressful events, and
suicidal behaviour.
Conclusion and implications
Among these vulnerable adolescents, stressful life events
begin in school and then move on to the domains of family,
self and friends. Our ndings provide specic indicators for
practical preventive interventions: the provision of timely
and appropriate help to families grappling with multiple
crises, especially families with adolescents. Clinical inter-
ventions especially in schools focusing on the develop-
ment and mastery of healthy coping may be more effective
before age 15.
REFERENCES
Agerbo, E. (2008). High income, employment, postgraduate education, and
marriage: a suicidal cocktail among psychiatric patients. Archives of General
Psychiatr y, 64(12), 1377-1384. Errat um in: Archives of General Psychiatry. 2008,
65(2),1 44.
Angold, A . (1989). Struct ured assessment of psychopathology in children and
adolescents. In: Thompson C (ed) The instruments of psychiatric research.
Chichester: John Wiley, pp 271-304.
Bridge, J. A., Goldstein, T.R ., & Brent, D.A. (2006). Adole scent suicide and suici dal
behaviour. Journal of Child Psychology and Psychiatry, 47, 372-394.
Coddington, R.D. (1972). The signicance of life events as etiolo gic factors in the
diseases of chil dren. II. A study of a nor mal population. Jour nal of Psychosoma-
tic Research, 16, 205–213.
Colton, J. (1985). Childho od Stress. Perception s of Children and Professionals.
Journal of Psychopathology and Behavioural Assessment, 17, 155-172.
Suicidal adoles-
cents may have
difficulties in se-
eing their personal
contributions to
stressful situations
which in turn could
lead to a reduction
in the use of
healthy coping
Attempters and
repeaters appeared
to be more similar
than dissimilar.
Together, they dif-
fered sharply from
the non-attempters.
48 suicidologi nr 2/2015
Attempted suicide and repeated attempts from adolescence to early adulthood: depression and stressful events
Cooper, P.J. & Goodyer, I. (1993). A communit y study of depression in adoles-
cent girls. I: Estimates of sy mptoms and syndrome prevalence. Br itish Jour nal
of Psychiatr y, 163 , 369-374.
Field, A. (2005). Discoverin g Statistics Using SPSS. 2nd edition, 2005 . Sage
Publications, London .
Forman, E .M., Berk , M.S., Henriques, G.R., Brown, G.K., & Beck, A.T. (2004).
History of Multiple Suicide Attempts as a B ehavioural Marker of Severe Psycho-
pathology. American Journal of Ps ychiatry, 161, 437-443.
Gladstone, G.L., Parker, G.B., Mitchell, P.B., Malhi, G.S., Wilhelm, K., & Austin ,
M.P. (2004). Implication s of Childhood Trauma for Depressed Women: An Ana-
lysis of Pathways from Childhood Sexual Abuse to Deliberate Self-Harm and
Revict imization. American Journal of Psychiatry, 161, 1417-1425.
Gould, M., Fischer, P., Parides, M., Flory, M., & Shaffer, D. (1996). Psychosoci-
al risk factors of child and adolescent completed suic ide. Archives of G eneral
Psychiatr y, 53, 1155-1162.
Gould, M. S., Greenberg, T., Velting, D.M., & Shaf fer, D. (2003). Youth Suicide Risk
and Prevent ive Intervent ions: A Rev iew of the Past 10 Years. Jour nal of Ameri-
can Academy of Child and Adolescent Psychiatr y, 42, 386-405.
Gould, B., Ekeberg, Ø., Wich strøm, L., & Haldorsen, T. (1997). Youth suicide in
Norway, 1990-1992: A comparison bet ween children and adolescents comple-
ting suicide and age-and gender-matched controls. Suicide & Life Threatening
Behav iour, 27, 250 -263.
Grøholt, B., Ekeberg, Ø., Wichstrøm, L ., & Haldorsen, T. (1998). Suicide among
children and younger and older adolescents in Nor way: a comparative study.
Journal of Amer ican Academy of Child and Adolescent Psychiatry, 37, 473-481.
Hultén, A., Jian g, G.X., Wasserman, D., Hawton, K ., Hjelmeland, H., De Leo, D.,
Ostamo, A., Salander-Renberg, E., Schmidtke, A . (2001). Repetition of attempted
suicide among teenagers in Europe: frequenc y, timing and risk factors. Euro-
pean Child & Adolescent Psychiatry, 10(3), 161-169.
Johnson, J.G., Cohen, P., Gould, M.S., Kasen, S., Brown, J., & Brook , J.S. (2002).
Childhood Adversities, Inter personal Difculties and Risk for Suicide Attempts
during Late Adolescence and Early Adulthood . Archives of General Psychiatr y,
59, 741- 749.
Joiner, T.E. Jr., Sachs-Ericsson , N.J., Wingate, L.R ., Brown, J.S., Anestis, M. D., &
Selby, E.A. (2007). Childhood physical and sexual abuse and lifet ime number
of suicide attempts: A persistent and theoretically important relationship. Be-
haviour Research and Therapy, 45, 539-577.
Kaufman, J., Birmaher, B., Brent, D., Rao, U., Fly nn, C., Moreci, P., et al. (1997).
Schedule for Affective Disorders and Schizophrenia for School-Age Children-
Present and Lifetime Version (K-SADS-PL): initial reliability and validity data.
Journal of Amer ican Academy of Child and Adolescent Psychiatry, 36, 980- 988.
Kent, L., Vostanis, P., & Feehan, C. (1997). Detection of major and minor depres-
sion in children and adolescents: evaluation of the Mo od and Feelings Questi-
onnaire. Journ al of Child Psychology and Psychiatry and Allied Disciplines, 38,
565-573.
King, R.A ., Schwab-Stone, M., Flisher, A.J., Greenwald, S., Kramer, R.A., Go od-
man, S.H ., et al. (2001). Psychosocial and Risk Behaviour Correlates of Youth
Suicide Attempts and Suicidal Ideation . Journal of American Academy of Child
and Adolescent Psychiatr y, 40, 837-846.
Lewinsohn, P.M., Rohde, P., Seeley, M.S., & Baldwin, C.L. (2001). Gender Diffe-
rences in Suicide Attempts from Adolescence to Young Adulthood. Journal of
American Academy of Child and Adolescent Psychiatry, 40, 427-434.
Norusis, M.J. (2004). SPSS 13.0 Advanced Statistical Procedures Companion.
Prentice Hall, Inc., New Jersey.
Nrugham, L., Larsson, B., & Sund, A.M. (2008). Predictors of suicidal acts across
adolescence: inuences of familial, peer and indiv idual factors. Journal of Affe-
ctive Disorders, 109, 35-45.
Nrugham, L., Holen, A., & Sund, A .M. (2010). Associations between attempted
suicide, v iolent life events, depression , and resilience by early adulthood. Jour-
nal of Nervou s and Mental Disease. 198(2), 131-136. Erratum: 198(5), 389.
Mann, J.J., Waternaux, C., Haas, G.L ., Malone, K.M. (1999). Towards a clinical
model of suicidal behavior in psychiatr ic patients. American Journal of Psychi-
atry, 156, 181–189.
Myers, K., McC auley, E., Calderon , R., Mitchell, J., Burke, P., & Schloredt, K. (1991).
Risks for suic idality in major depressi ve disorder. Journal of American A cademy
of Child & Adolescent Psychiat ry, 30, 86-94.
Paykel, E. S. (2001). The evolution of life event s research in psychiatry. Journ al of
Affective Di sorders, 62 , 141-149.
Portzk y, G., Audenaert , K., & van Heeringen, Kees . (2005). Suicide among adole s-
cents: A psychological autopsy study of psychi atric, psychosocial and person a-
lity-related factors. Social Psychiatry & Psychiatr ic Epidemiology, 40, 922- 930.
Rudd, D. M., Joiner, T. E., & Rajab, M. H. (1996). Relationships among suicide
ideators, attempters, and multiple attempters in a young-adult sample. Journal
of Abnormal Psychology, 105, 5 41–550.
Sheikholeslami, H., Kani, C., Kani, K., Ghafelebashi, H. (2009). Repetition of
suicide-related behavior: a study of the characteristics, psychopathology, sui-
cidality an d negative life events in Iran. Inter national Journal of Psychiatry in
Medicine. 39(1), 45-62.
Sund, A.M., Larsson, B.S., & Wichstrøm , L. (2001). Depressive symptoms among
young Nor wegian adolescents as mea sured by the Mood and Feelings Qu estion-
naire (MFQ). European Journal of Child and Adolescent Psychi atry, 10, 222-229.
Sund, A.M., Larsson, B.S., & Wichstrøm , L. (2003). Psychosocial correlates of
depressive symptoms among 12-14-year-old Nor wegian adolescents. Journal of
Child Psychology and Psychiatry, 44, 588-597.
Swearingen, E.M., & Cohen, L.H. (1985). Measurement of adolescents' life
events: the junior high life exper iences sur vey. American Jour nal of Community
Psychology, 13, 69-85.
Tabachnick, B.G ., & Fidell, L . (2006). Using multivariate statistics, 5th edition,
2006. Ally n and Bacon. Boston.
Wagner, B.M., Cole, R.E., & Schwar tzman, P. (1995). Psycholo gical correlates of
suicide at tempts among junior and senior hi gh school youth. Suicide & Life T hre-
atening Behaviour, 25, 358-372.
Wichstrøm, L. (200 0). Predictors of adolescent suic ide attempts: a nationally re-
presentative longitudinal study of Nor wegian adolescents. Jour nal of American
Academy of Child an d Adolescent Psychiatr y, 39, 603-610.
Wilson, K.G., Stelzer, J., Bergman , J.N., Kral, M.J., Inayat ullah, M., & Elliott, C.A.
(1995). Problem solv ing, stress, and coping in adolescent suicide at tempts. Suici-
de & Life Threatening Behaviour, 25, 241-252.
Wood, A., Kroll , L., Moore, A. & Har rington, R. (1995). Prop erties of the Mood an d
Feelings Questionnaire in adolescent psychiat ric outpatients: a research note.
Journal of Chil d Psychology and Psychiatry and Allied Di sciplines, 36, 327-334.
Levert: 03.03.15,
Re vid ert: 0 8.0 6.15
Godkjent: 29.06.15
LATHA NRUGHAM worked on the research project:
’Youth and Depression’ led by Prof. Anne M ari Sund,
for her doctoral work at the Facult y of Medicine,
NTNU, with Prof. Are Holen as her guide and succ ess-
fully defended it in 2010 when s he was also Senior
Researcher at the National Centre for Suicide Rese-
arch and Prevention. She resigned from this position
in 2014 and is currently living with her husband in the
Himalaya. Foto: Mugdha Sukhramani
ARE HOL EN MD, PhD is a psychiatrist and Professor
emeritus at the Dept. of Neuroscience, Norwegian
University of Science and Technology (NTNU), Trond-
heim, Norway. His main area of researc h is life events,
major stressors and posttraumatic stress. He has also
been involved in research in other areas related to
psychiatry, psychology, group dynamics and medical
education.
ANNE MARI SUND
is a consultant and professor in
child and adolescent psychiatry and works at the
Regional Centre for Child and Youth Mental Health
and Child Welfare, NTNU and St. Olav ’s Hospit al.
She is leading and participating in various epidemio-
logical and intervention studies.
suicidologi nr 2/2015 49
Attempted suicide and repeated attempts from adolescence to early adulthood: depression and stressful events
