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Specific depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence

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Abstract

To examine the role of depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence. A representative sample of Norwegian school students (N = 2464, mean age 13.7 years) in grades 8 and 9 was reassessed after one year (T2) with the same questionnaire. All high scorers of depressive symptoms on the Mood and Feelings Questionnaire (MFQ) at T2 were defined as cases. One control from low or middle scorers, matched for age and gender, was randomly assigned to every two cases. This subset (n = 345) was diagnostically assessed by face-to-face K-SADS-PL interviews (mean age = 14.9 years). The same subset was reassessed after 5 years (T3) by using the same questionnaire (n = 252, mean age = 20.0 years) and telephone K-SADS-PL interviews (n = 242). The participation rate was 76.9% (n = 265). Cognitive symptoms dominated the depressive symptom profile among suicide attempters, irrespective of age and time. Among younger adolescents, suicidal thoughts and acts of self-harm without suicidal intent were associated with suicidal acts. Recurrent thoughts about death, hopelessness, disturbed concentration and middle insomnia were associates of suicidal acts among older adolescents. Worthlessness by 15 years was a significant predictor of suicidal acts between 15 to 20 years. MDD and a depressive episode, not otherwise specified, continued to be significant associates among younger adolescents, while dysthymia by 15 years remained a predictor of suicidal acts between 15 to 20 years, even when controlled for depressive symptoms. Self-harm without suicidal intent, middle insomnia, cognitive depressive symptoms and a formal psychiatric diagnosis of any depressive disorder should alert professionals in the risk assessment of suicidal adolescents.
Research report
Specific depressive symptoms and disorders as associates and
predictors of suicidal acts across adolescence
Latha Nrugham
a,
, Bo Larsson
a
, Anne Mari Sund
a,b
a
Regional Centre for Child and Adolescent Mental Health, Department of Neuroscience, Faculty of Medicine,
Norwegian University of Science and Technology, Trondheim, Norway
b
Department of Child and Adolescent Psychiatry, St.Olav's University Hospital, Trondheim, Norway
Received 25 July 2007; received in revised form 6 February 2008; accepted 7 February 2008
Available online 18 April 2008
Abstract
Objective: To examine the role of depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence.
Method: A representative sample of Norwegian school students (N= 2464, mean age 13.7 years) in grades 8 and 9 was reassessed after
one year (T2) with the same questionnaire. All high scorers of depressive symptoms on the Mood and Feelings Questionnaire (MFQ)
at T2 were defined as cases. One control from low or middle scorers, matched for age and gender, was randomly assigned to every two
cases. This subset (n= 345) was diagnostically assessed by face-to-face K-SADS-PL interviews (mean age = 14.9 years). The same
subset was reassessed after 5 years (T3) by using the same questionnaire (n= 252, mean age = 20.0 years) and telephone K-SADS-PL
interviews (n= 242). The participation rate was 76.9% (n= 265).
Results: Cognitive symptoms dominated the depressive symptom profile among suicide attempters, irrespective of age and time.
Among younger adolescents, suicidal thoughts and acts of self-harm without suicidal intent were associated with suicidal acts.
Recurrent thoughts about death, hopelessness, disturbed concentration and middle insomnia were associates of suicidal acts among
older adolescents.
Worthlessness by 15 years was a significant predictor of suicidal acts between 15 to 20 years. MDD and a depressive episode,
not otherwise specified, continued to be significant associates among younger adolescents, while dysthymia by 15 years remained a
predictor of suicidal acts between 15 to 20 years, even when controlled for depressive symptoms.
Conclusions: Self-harm without suicidal intent, middle insomnia, cognitive depressive symptoms and a formal psychiatric
diagnosis of any depressive disorder should alert professionals in the risk assessment of suicidal adolescents.
© 2008 Elsevier B.V. All rights reserved.
Keywords: Longitudinal; Case-control; School adolescents; Young adults
1. Introduction
The assessment of suicidal youth is one of most com-
mon and demanding emergencies in adolescent mental
health services (Brent, 2001). The ratio of suicide attempts
to suicide completions is higher in adolescence than in
any other age group (King, 1997). The prevalence of
Journal of Affective Disorders 111 (2008) 8393
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E-mail address: latha.nrugham@medisin.uio.no (L. Nrugham).
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suicide attempts starts increasing from the age of 14 years
onwards (Lewinsohn et al., 2001a). Up to 32% of
clinically referred adolescents will attempt suicide at
least once by early adulthood (Kovacs et al., 1993), while
20% will repeat the attempt (Harrington et al., 1994). In
community settings, 7091% of youth who attempt or
think about suicide have a psychiatric disorder (Gould
et al., 1998). Research on suicidal phenomena among
adolescents has mainly explored for other risk factors
associated with depressive disorders (Brent et al., 1994;
Lewinsohn et al., 2001a; Bridge et al., 2006), since most
persons with mood disorders do not commit suicide and
about half of them never attempt suicide (Rihmer, 2007).
Depressed mood has been found to be the most
common depressive symptom among 11 to 18 year old
adolescent inpatients and outpatients who have attempted
suicide (Bettes and Walker, 1986). Among adolescent
emergency unit inpatients, high levels of self-reported
depressive symptoms predicted suicide attempts in a 2 to
4yearfollow-up(Ivarsson et al., 1998). Among 13 to
17 year olds, hopelessness, negative self-esteem and
violent behaviour were more common among depressed,
suicidal adolescents than among those who are depressed
but non-suicidal (Csorba et al., 2003). A recent review on
sleep and suicidal behaviour among youth has called for
the use of longitudinal studies due to inconsistencies in
findings of cross-sectional studies, wherein the associa-
tions with insomnia often disappeared when controlled
for depression (Liu and Buysse, 2006).
Major depressive disorder (MDD) and dysthymia were
specifically associated with higher rates of suicidal
behaviours than other diagnoses among outpatients aged
813 years, followed up for five years (Kovacs et al.,
1993). MDD has also been significantly associated with
suicidal acts among older school adolescents (Lewinsohn
et al., 1994).
Although current empirical research has added con-
siderably to our knowledge on sucidality among
adolescents, gaps continue to exist about specific aspects
which can potentially aid the clinician in the assessment
of suicide risk among adolescents, for example: are there
specific depressive symptoms and disorders related to
suicidal acts? Do these relationships differ with age and
time? To the best of our knowledge, longitudinal studies
exploring the role of specific depressive symptoms and
disorders as associates and predictors of suicidal acts
among adolescents have not yet been reported.
The aim of the current study was, therefore, to ex-
amine relationships between specific depressive symp-
toms and disorders with suicidal acts in a sample of
depressed school adolescents and non-depressed controls
followed for a five-year period into early adulthood. We
first studied the prevalence of depressive symptoms and
disorders in adolescents with high mean scores on
depressive symptoms as compared to those with low to
moderate mean scores as reported in a questionnaire. The
next objective was to examine the specificity of
depressive symptom and diagnostic profiles as associates
of suicidal acts at two developmental phases, i.e., by
15 years and for the next 5-year period as assessed
retrospectively at 20 years of age. Thirdly, we explored
the role of specific depressive symptoms and disorders by
the age of 15 years as potential prospective predictors of
suicidal acts between 15 to 20 years of age. Finally, we
investigated the role of self-harm without suicidal intent
as an associate and predictor of suicidal acts, across age
and time, given its complex relationship with suicidal
acts (Grøholt et al., 2000; Jacobson and Gould, 2007;
Larsson and Sund, 2008).
2. Methods
2.1. Participants and procedures
The participants were selected from a school sample
of adolescents in 8th and 9th grades in 1998 from two
counties in Central Norway. A cluster sampling tech-
nique resulted in a representative sample of 2792 stu-
dents from 22 schools. Based on prevalence estimates
of 510% of MDD among adolescents in the gen-
eral population (Lewinsohn et al., 1998; DSM-IV-TR,
2000), we calculated that a sufficient number of
participants with a formal diagnosis of depressive dis-
order would be included in the present study to provide
powerful comparisons with non-depressed adolescents.
A detailed description of the sampling procedure and
the original sample is provided elsewhere (Sund et al.,
2001, 2003).
2.2. Assessment points
At the first assessment, (T1), 2464 (N
1
) adolescents
with a mean age of 13.7 (SD = 0.5) years and a par-
ticipation rate of 88.3% (50.8% females) entered the
project. A questionnaire, including a screening measure
for depressive symptoms, was completed at school. At
the second assessment (T2), 2432 (N
2
) adolescents with
a mean age of 14.9 (SD = 0.5) years, with a participation
rate of 86.7% (50.3% females) completed the same
questionnaire again at school.
2.2.1. Subset selection
On the basis of the mean total scores for depressive
symptoms on the Mood and Feeling Questionnaire
84 L. Nrugham et al. / Journal of Affective Disorders 111 (2008) 8393
(MFQ) (described below), at T2, the participants were
grouped into three levels: low (06), middle (724) and
high (25 and above) scorers. All high scorers were
regarded as cases. One control for every two cases was
selected at random from the low and middle scorers,
matched for age and gender. Of the 364 adolescents thus
selected, 345 were diagnostically interviewed face-to-
face by trained interviewers at school. The cases
numbered 224 (64.9%) and the controls, 121 (35%).
The participation rate was 94.7% and included 72.5%
females.
At the third assessment (T3), 265 young adults (N
3
)
with a mean age of 20.0 (SD = 0.5) years and a
participation rate of 76.9% (77% females) were
reassessed. Two hundred and fifty-two young adults
(73%) completed the questionnaire with a mean age of
20.0 (SD = 0.6) years, of whom 77% of them were
females. For the interviews, the participation rate was
70.1% (n= 242) with a mean age of 20.0
(SD = 0.6) years, of whom 76.9% were females. Of the
224 high scorers on the MFQ at T2, 155 were re-
interviewed at T3, with a participation rate of 69.1%.
The non-participants at T3 were significantly more
often males, [χ
2
(1)= 6.5, pb0.01]. While the non-
participants reported significantly higher depressive
symptoms scores on the MFQ at T1 (M= 12.8,
SD= 11.0) than the participants (M=10.3, SD=8.8), t
(343)= 2.0, pb0.05 (effect size of r=.10), no difference
between the participants and non-participants was found
for mean depressive symptom scores on the MFQ, de-
pressive disorders or suicidal acts as assessed at T2.
2.3. Measures
2.3.1. Questionnaire
2.3.1.1. Mood and Feelings Questionnaire (MFQ).
This measure, which was developed for 818 year olds
and includes all depressive symptoms based on DSM-III-
R criteria for major depression (Angold, 1989), was
chosen since it is adolescent-friendly in its wording. The
cut-off score for grouping of high scorers as a category
was chosen on the basis of the assessment of the 2464
adolescents with the MFQ one year (T1) before the
interviewing study, when the 90th percentile was at 24.
The participants were asked about their feelings and
behaviours in the last 2 weeks for 34 items rated on a 02
scale with a total score range of 068. Psychometric
properties of the MFQ in the original sample have been
found to be satisfactory (Sund et al., 2001). A detailed
analysis of MFQ scores and suicidal acts across
adolescence revealed that respondents with suicidal acts
had significantly higher mean scores at all three
assessment points (Nrugham et al., 2008).
2.3.2. Interview
2.3.2.1. The Kiddie Schedule for Affective Disorders
and Schizophrenia Present and Lifetime version (K-
SADS-PL). This well established semi-structured
diagnostic interview is built to assess present and past
episodes of psychopathology in children and adolescents
on Axis I according to DSM-III-R and IV-TR criteria
(Kaufman et al., 1997). Each individual symptom is rated
on a 03 scale, with a score of 3 representing clinical
threshold.
Experienced clinicians trained in psychopathology
and the use of K-SADS-PL conducted the interviews.
The interviewers were blind to the case/control status
of the participant, at both interview assessments, i.e.,
T2 and T3. The average interval between filling out
the questionnaires and interviews was 20 days at T2
and 21 days at T3. Inter Rater Reliability (IRR) for all
K-SADS symptoms at the end of training and before
initiation of real interviews, was good, with Cohen's
kappa of 0.71 at T2 and 0.70 at T3 with the third
author, an experienced child psychiatrist. Interview in-
tegrity was maintained at T2 and T3 with average
kappas of 0.83 and 0.80, respectively, for all screening
symptoms and affective supplement symptoms.
At T2, 79.8% of the adolescents had at least one parent
as a separate informant. Summary symptom scores and
diagnostic assessments were based on information ob-
tained from both informants. A diagnosis of depressive
disorder and its co-morbidity was investigated for the
lifetime period, i.e., up to15 years of age. At T3, the young
adults were randomly allocated to interviewers.
The interviews at T3 were conducted on telephone
and explored psychopathology for the five-year follow-
up period retrospectively, i.e., from 15 to 20 years of
age. In a comparative study of follow-up interviews of
young adults, the use of telephone interviews as follow-
ups of face-to-face interviews has been found to be as
reliable as face-to-face psychiatric interviews for Axis I
and II psychopathology with substantial economic and
logistic advantages (Rohde et al., 1997). The K-SADS
PL interviews also provide information regarding
functioning levels in three areas: family, school/work
and friends.
2.3.3. Key variables
2.3.3.1. Depressive symptoms. K-SADS-PL provides
a list of 30 items, with guidelines to assess sub-clinical
85L. Nrugham et al. / Journal of Affective Disorders 111 (2008) 8393
and clinical thresholds, to probe for all DSM-IV-TR
symptoms in a depressive episode, including all sub-
types of major depression and dysthymia. The screening
section for a depressive episode has eight items and a
threshold score in the screening indicates the use of
supplement items. A clinical threshold score on items
assessing various aspects of depressive symptoms was
required for entry into analysis. Medical lethality of
suicidal acts was excluded from the present study since
it is not a DSM-IV-TR criterion for a depressive episode
or a subtype of depressive episode.
2.3.3.2. Depressive disorders. Diagnoses of depres-
sive disorders included Major Depressive Disorder
(MDD) and dysthymia based on DSM-IV-TR criteria.
However, in the present study, a diagnosis of Depressive
Disorder Not Otherwise Specified (DD-NOS) required
at least three depressive symptoms lasting for at least
two weeks. Probes for a diagnosis of any depressive
disorder were limited to the most serious past episode.
Functional impairment, as measured by Childhood-
Global Assessment of Symptoms (C-GAS), was a
requirement for a diagnosis of MDD or dysthymia
during the diagnostic assessments (Shaffer et al., 1983).
All respondents with a formal diagnosis of MDD had
either reduced functioning or a CGAS score below 71.
However, two young adults had a diagnosis of MDD at
T3, with a C-GAS score above 71, in spite of reduced
functioning. For the purpose of analysis, current and
past diagnoses were pooled together, as was done with
depressive symptoms. For example, an episode of MDD
present at anytime up to the age of 15 years was
recorded as MDD, irrespective of whether it was current
or past. However, if, one individual had more than one
diagnosis of depressive disorder, each such diagnosis
was considered (Helzer et al., 2006).
2.3.3.3. Suicidal acts. Positive responses to items on
suicidal acts, either in the questionnaire or the interview
were used. Suicidal acts and acts of self-harm without
suicidal intent were assessed on separate items, both in
the interview and questionnaire. Acts of self-harm
without suicidal intent were differentiated from suicidal
acts, either by the respondent in the questionnaire or the
interviewer using either seriousness of suicidal intent or
lethality or both. Ambiguous instances were defined as
sub-threshold levels of suicidal acts. Acts of self-harm
without suicidal intent and sub-threshold levels of
suicidal acts were excluded from the definition of
suicidal acts.
The item used in the questionnaire was the same as in
a previous, national survey of youth, Young in Norway
(Wichstrøm, 2000): Have you ever tried to commit
suicide?. The response options were: No, never;
Yes, once;Yes, several times. All respondents who
answered positive to this item were defined as at-
empters. Questions on suicidal behaviour were parts of
the screening probes for depression in the K-SADS. A
positive response to the question: Have you ever (or
since the last interview) tried to kill yourself or done
something which could have killed you?and assessed
to have reached the clinical threshold level by the
interviewer was defined as a suicidal act. Thus, two
groups were formed: those who reported never to have
attempted a suicidal act as non-attempters and those who
had reported a suicidal act at any one assessment (T1,
T2, or T3), as attempters.
The assessments were approved by the local school
authorities, the school boards and the Regional
Committee for Medical Research Ethics, Central Nor-
way. Based on standards prescribed by The Norwegian
Data Inspectorate, informed consent was obtained from
the participants at all assessment points.
2.4. Statistics
Descriptive methods were used to examine frequencies
of depressive symptoms and disorders. A series of bi-
variate logistic regression models were conducted to
examine crude estimates for potential associates and pre-
dictors. All depressive symptoms and disorders providing
significant Odds Ratios (ORs) at pb.01 level were
subsequently entered into multivariate logistic regression
analyses run separately for age and time. Multicollinearity
diagnostics revealed minor problems for data at T3 with
hypersomnia (.29) and hopelessness (.46) loading to-
gether leading to both being excluded from analyses
(Field, 2005). The multivariate analyses used the standard
method of entry and significance level was set to pb.05.
3. Results
3.1. Frequency of depressive symptoms and disorders
by 15 years of age and between 15 to 20 years of age
Depressed mood was found to be the most frequent
symptom at both assessment points (T2 and T3), (see
Table 1), while the next highest frequencies changed
according to age and time. The frequency and distribu-
tion of depressive diagnoses also differed with age. In
the younger age group, MDD and DD-NOS constituted
76.1% of the depressive diagnoses with a roughly equal
distribution between them, while among older sub-
jects, these two diagnoses accounted for 86.6% of the
86 L. Nrugham et al. / Journal of Affective Disorders 111 (2008) 8393
depressive diagnoses and MDD dominated the picture.
However, higher mean scores of depressive symptoms
on the MFQ at 15 years were more strongly associated
with suicidal acts by 15 years [OR (95% CI) = 6.5(3.1
13.5)] than with any depressive disorders by 15 years
[OR (95% CI) = 4.4(2.77.4)].
3.2. Associates of suicidal acts performed by 15 years
of age
The results of the first set of bivariate logistic re-
gression analyses which examined depressive symptoms
and disorders assessed at 15 years (T2), retrospectively for
lifetime, (see Tabl e 2), showed that suicidal thoughts, self-
harm without suicidal intent, Circadian reversals and
hopelessness were most strongly associated with suici-
dal acts. Among diagnoses, MDD and DD-NOS were
significant and strong associates of suicidal acts.
3.3. Associates of suicidal acts performed between 15
to 20 years of age
The results of the next set of bivariate logistic regres-
sion analyses which focussed on the role of depressive
Table 1
Percentages of depressive symptoms and diagnoses in a subset of non-depressed and depressed school adolescents as assessed by K-SADS interviews
at two assessments, T2 (at 15 years) and T3 (at 20 years) and grouped into high and low scorers on the Mood and Feelings Questionnaire (MFQ)
T2 (n= 345) T3 (n= 242)
Depressive symptoms/diagnoses MFQ low
scorers
(n= 121)
MFQ high
scorers
(n= 224)
All MFQ low
scorers
(n = 87)
MFQ high
scorers
(n= 155)
All
Depressed mood 24 58 46.1 32.2 57.4 48.3
Irritable mood 14.9 32.6 26.4 13.8 28.4 23.1
Anhedonia 9.1 18.8 15.4 13.8 25.8 21.5
Initial insomnia 3.3 24.1 16.8 14.9 32.9 26.4
Middle insomnia 1.7 8.9 6.4 6.9 19.4 14.9
Terminal insomnia 2.5 7.1 5.5 6.9 9.7 8.7
Circadian reversal 1.7 11.6 8.1 9.2 21.3 16.9
Non-restorative sleep 6.6 22.8 17.1 20.7 31 27.3
Hypersomnia 0.8 10.3 7 12.6 26.5 21.5
Decreased appetite 2.5 13.8 9.9 12.6 19.4 16.9
Weight loss 0 5.4 3.5 3.4 5.8 5
Increased appetite 0.8 5.8 4.1 2.3 7.7 5.8
Weight gain 0 1.8 1.2 0 2.6 1.7
Psychomotor agitation 5.8 5.8 5.8 3.4 9 7
Psychomotor retardation 1.7 9.4 6.7 8 12.3 10.7
Fatigue 11.6 34.8 25.5 25.3 40.6 35.1
Disturbed concentration 8.3 34.8 26.7 16.1 31.0 25.6
Indecisiveness 3.3 14.3 10.4 6.9 11.6 9.9
Worthlessness 15.7 26.3 22.6 20.7 31.6 27.7
Excessive guilt 3.3 13.8 10.1 11.5 18.7 16.1
Hopelessness 9.1 21.9 17.4 11.5 27.1 21.5
Recurrent thoughts about death 10.7 38.4 28.7 11.5 27.1 21.5
Suicidal thoughts 5.8 21.4 15.9 12.6 21.3 18.2
Suicidal acts 3.3 24.1 8.1 1.1 10.3 7
Self-harm without suicidal intent 0.8 7.1 4.9 4.6 12.3 9.5
Non-reactive mood 11.6 25 20.3 19.5 32.9 28.1
Depressed mood qualitatively
different from grief
13.2 33.0 26.1 11.5 24.5 19.8
Diurnal variation morning 1.7 9.8 7 1.1 3.9 2.9
Diurnal variation evening 13.2 26.8 22 11.5 21.9 18.2
Increased sensitivity to rejection 9.1 18.3 15.1 5.7 7.7 7
MDD 5.7 25.9 18.8 19.5 38.7 31.8
Dysthymia 5.7 15.1 11.9 3.4 6.4 5.4
DD-NOS 10.7 23.6 19.1 4.5 5.8 5.4
87L. Nrugham et al. / Journal of Affective Disorders 111 (2008) 8393
symptoms and disorders as assessed retrospectively at
20 years of age (T3) (Table 2), showed that recurrent
thoughts about death, suicidal thoughts, hopelessness
and self-harm without suicidal intent were the strongest
associates of suicidal acts. All sleep disturbances, except
terminal insomnia, were significantly associated with
suicide attempts. Although only MDD was a significant
associate with suicidal acts, the Odds Ratio (OR) for
MDD in the older age group was twice as high for those
in the younger age group.
3.4. Predictors of suicidal acts performed between 15
to 20 years of age
The results of the last set of bivariate logistic regres-
sion analyses which investigated depressive symptoms
and disorders reported by 15 years (T2) (Table 2),
showed that suicidal acts, depressed mood, worthless-
ness and excessive guilt were the strongest prospective
predictors. However, the number of significant depres-
sive symptoms was fewer than those obtained in the
Table 2
Results of bivariate logistic regression of depressive symptoms and diagnoses as associates and predictors of suicidal acts (SA) across adolescence
Depressive symptoms/
diagnoses by 15 years as
associates of suicidal acts
by 15 years
(n= 345) (SA = 86)
Depressive symptoms/diagnoses
between 1520 years as
associates of suicidal acts
between 1520 years
(n= 242) (SA = 34)
Depressive symptoms/
diagnoses by 15 years as
predictors of suicidal acts
between 1520 years
(n= 265) (SA = 36)
Depressive symptoms χ
2
OR (95% CI) χ
2
OR (95% CI) χ
2
OR (95% CI)
Depressed mood 22.3** 3.3(1.95.5) 32.8*** 14.6(4.349.4) 20.1*** 5.7(2.413.4)
Irritable mood 9.1** 2.2(1.33.8) 11.1** 3.7(1.77.9) 6.1* 2.4(1.25)
Anhedonia 6.3* 2.2(1.24.1) 23.2*** 6.7(3.114.5) 10.7** 3.8(1.78.1)
Appetite 16.3*** 4.5(2.19.3) 5.7* 2.8(1.26.4) 1.8 2(.75.2)
Weight loss 3.6 3.1(.910) 1 2.1(.58.3) 2.7 3.8(.816.6)
Appetite 6.7** 4.2(1.412.6) 7.4** 5.3(1.716.5) 3.7* 3.7(1.112.6)
Weight gain 1.1 3(.422) 2.9 6.4(.847.3) .6 2.9(.2 28.1)
Initial insomnia 26.2*** 4.7(2.68.5) 10.1** 3.4(1.67.2) 8.8** 3.3(1.57)
Middle insomnia 4.5 2.6(1.16.4) 17*** 5.9(2.613.3) .04 .8(.13.7)
Terminal insomnia 4.6 2.8(1.17.2) 5.6 3.5(1.39.6) .6 .4(.063.5)
Circadian reversal 17.4*** 5.4(2.412.1) 16.8*** 5.5(2.512.2) 3.2 2.6(.9 6.9)
Non-restorative sleep 25.1*** 4.5(2.58.1) 14.6*** 4.3(29.1) 2.8 2(.94.4)
Hypersomnia 2 1.9(.84.5) 10.4** 3.6(1.67.8) 7.1** 4.1(1.510.8)
Agitation 3.9 2.5(1.036.4) 5.3 3.8(1.311.1) .05 1.2(.25.7)
Retardation 5.8 2.9(1.26.9) 5.5 3.2(1.28.2) .08 .8(.13.5)
Fatigue 7.4** 2(1.23.5) 20.8*** 5.7(2.612.8) 5* 2.3(1.14.7)
Disturbed concentration 20.7*** 3.3(2.05.6) 36.4*** 10.7(4.724.3) 10** 3.1(1.56.4)
Indecisiveness 1.4 1.5(.73.3) 12.6*** 5.7(2.314.4) 2.9 2.3(.95.7)
Worthlessness 29.9*** 4.5(2.67.8) 28*** 7.7(3.517.2) 20.9*** 5.4(2.611)
Excessive guilt 12.4*** 3.6(1.87.5) 14.8*** 5.1(2.311.4) 13.4*** 5.2(2.211.8)
Hopelessness 30.3*** 5.2(2.99.4) 46.3*** 15.4(6.635.6) 6* 2.7(1.25.8)
Death thoughts 31.2*** 4.3(2.57.2) 58*** 22.7(9.355.5) 6.2* 2.4(1.24.9)
Suicidal thoughts 49.0*** 8.8(4.716.7) 56*** 22.5(9.453.8) 3.6* 2.2(14.9)
Suicidal acts 14.4*** 6.2(2.614.8)
Self-harm no suicidal intent 16.3*** 8(2.723.7) 31.8*** 15.4(5.940.2) .4 .5(.064)
Non-reactive mood 23.0*** 3.9(2.26.9) 23.4*** 6.4(2.914) 3.7* 2.1(14.5)
Mood different from grief 9.6** 2.3(1.33.9) 5.2* 2.6(1.15.7) 6.3* 2.5(1.25.1)
Diurnal variation morning 7.3** 3.2(1.47.6) 1 2.5(.413.6) .9 1.8(.55.6)
Diurnal variation evening 5.2* 1.9(1.13.3) 3 2.1(.94.8) 2.7 1.9(.94)
Sensitivity to rejection 8.6** 2.5(1.34.7) 2.9 2.8(.98.5) 1.4 1.7(.74)
Depressive diagnoses
MDD 20*** 3.7(2.16.9) 29.4*** 8.2 (3.618.4) 14.1*** 4.2(28.7)
Dysthymia 4.5* 2.1(1.054.2) 5.1* 4.3 (1.314) 13.3*** 4.8(2.110.6)
DD-NOS 12.2*** 2.8(1.54.9) .02 1.1 (.2 5.2) .8 1.4(.63.3)
Model Chi-square, p-values and odds ratios (95% confidence intervals).
Bold = variables entered into multivariate analyses. *pb.05, **pb0.01, ***pb0.001.
88 L. Nrugham et al. / Journal of Affective Disorders 111 (2008) 8393
cross-sectional analyses. MDD and dysthymia were
both, strong and significant predictors of suicidal acts.
3.5. Depressive symptoms and disorders as associates
and predictors of suicidal acts across adolescence:
results of multivariate analysis
3.5.1. Associates of suicidal acts performed by 15 years
of age
The multivariate logistic regression model for
associations between suicidal acts and statistically sig-
nificant depressive symptoms by 15 (T2), had two
depressive symptoms, i.e., suicidal thoughts and self-
harm without suicidal intent (Table 3). This cross-
sectional model had a χ
2
value of 82.4(df = 19),
pb.0005 and the Nagelkerke's R
2
value was at .31.
The Hosmer and Lemeshow statistic of 3.4 (df = 5) was
non-significant at .63. This model correctly classified
82% of all respondents, and 43% of the attempters.
When these depressive symptoms were compared
with the two depressive diagnoses which had emerged
as significant associates of suicidal acts by 15 years in
the bivariate analyses, a significant multivariate model
was obtained, with a χ
2
value of 63.5 (df = 4), pb.0005
and the Nagelkerke's R
2
value was at .24. The Hosmer
and Lemeshow statistic of 0.6 (df= 3) was non-sig-
nificant at .89. This model correctly classified 79.9% of
all respondents, and 40.7% of the attempters. This final
model of associates of suicidal acts by 15 years (T2) had
four significant variables, two depressive diagnoses:
MDD, OR (95%CI) = 2.6 (1.35.2), pb.01; DD-NOS,
OR (95%CI) = 2.3 (1.14.5), pb.05; and two depressive
symptoms: self-harm without suicidal intent, OR(95%
CI) = 3.5 (1.111.5), pb.05; and suicidal thoughts, OR
(95%CI) = 4.3 (2.18.8), pb.0005.
3.5.2. Associates of suicidal acts performed between 15
to 20 years of age
The multivariate logistic regression for associations
between suicidal acts and depressive symptoms between
15 to 20 years, as assessed at 20 years of age (T3), had
six depressive symptoms, three cognitive and three
somatic (Table 3). However, two of the significant
symptoms, i.e., increased appetite and initial insomnia,
were protective in nature. This cross-sectional model
had a χ
2
value of 102.8 (df = 19), pb.0005 and the
Nagelkerke's R
2
value was .62. The Hosmer and
Lemeshow statistic of 17.1 (df =4) was significant at
.002. This model correctly classified 93% of all
respondents and 67.6% of the attempters.
When these significant depressive symptoms were
compared with MDD, the depressive diagnosis which had
emerged as significant associates of suicidal acts between
15 to 20 years of age in the bivariate analyses, a significant
multivariate model was obtained, with a χ
2
value of 90.7
(df=7), pb.0005 and the Nagelkerke's R
2
value was at
.56. The Hosmer and Lemeshow statistic of 2.4 (df = 4)
was non-significant at .65. Overall, this model correctly
classified 85.8% of all respondents, and 89.7% of the
attempters. Although this final model did not retain MDD,
it included the following significant depressive symptoms:
recurring thoughts of death, OR (95%CI)= 14.6 (4.3
49.1), pb.0005; disturbed concentration, OR (95%CI) =
16.3 (3.870.1), pb.0005; hopelessness, OR (95%CI)=
8.3 (2.626.6), pb.0005 and initial insomnia, OR(95%
CI)=0.16 (0.00.6), pb.01.
3.5.3. Predictors of suicidal acts performed between 15
to 20 years of age
In the third multivariate logistic regression analy-
sis, depressive symptoms by 15 years as prospective
Table 3
Results of multivariate logistic regression as given by Odds Ratios (95% Confidence Intervals) of depressive symptoms as associates and predictors
of suicidal acts (SA) across adolescence
Depressive symptoms Depressive symptoms by
15 years as associates of
suicidal acts by 15 years
(n= 345) (SA = 86)
Depressive symptoms between
1520 years as associates of suicidal
acts between 1520 years
(n= 242) (SA = 34)
Depressive symptoms by 15 years
as predictors of suicidal acts between
1520 years
(n= 265) (SA = 36)
Recurrent thoughts about death 7.9 (1.443.1)*
Suicidal thoughts 3.7 (1.68.4)**
Self-harm without suicidal intent 4.5 (1.316.0)*
Worthlessness 3.3 (1.38.6)*
Hopelessness 26.5 (4.1168.5)***
Disturbed concentration 56.9 (5.6577.7)***
Increased appetite 0.05 (0.00.6)*
Initial insomnia 0.04 (0.00.4)**
Middle insomnia 6.0 (1.327.8)*
Note. *pb0.05; **pb0.01; ***pb0.001.
89L. Nrugham et al. / Journal of Affective Disorders 111 (2008) 8393
predictors of suicidal acts performed between 15 to
20 years were examined. This predictive model had only
one depressive symptom: worthlessness (Table 3). It had
aχ
2
value of 37.4 (df = 7), pb.0005. The Nagelkerke's
R
2
value was .24. The Hosmer and Lemeshow statistic
of 38.9(df = 4) was significant at .0005, revealing poor
calibration of the model. This model correctly classified
86.4% of all respondents and 13.9% of the attempters.
When the significant predictors which had emerged in
the bivariate analyses, that is worthlessness, MDD and
dysthymia were contrasted with each other, a significant
multivariate model was obtained, with a χ
2
value of 28.1
(df = 3), pb.0005 and Nagelkerke's R
2
value at .18. The
Hosmer and Lemeshow statistic of 11.1 (df= 3) was
significant at .01. This model correctly classified 86.8% of
all respondents and 16.7% of the attempters. This final
model included dysthymia, OR (95%CI)= 2.4 (1.06.2),
pb.05; and worthlessness, OR (95%CI)= 3.3 (1.38.2),
pb.01 as significant predictors of suicidal acts between
15 to 20 years.
4. Discussion
In the present study, the role of depressive symptoms
and disorders as associates and predictors of suicidal acts
across was examined in a subset of depressed and non-
depressed adolescents recruited from a representative
sample of Norwegian high school students, followed-
up for a five year period. The main findings were:
(a) cognitive symptoms dominated the depressive psy-
chopathology profile of adolescents with suicidal acts,
regardless of age and time (b) their roles differed with
age, and (c) the role of a formal psychiatric diagnosis of
depressive disorders changed according to time and age.
Among older adolescents, a decline in the frequency
of depressive symptoms was observed, with the ex-
ception of anhedonia, self-harm without suicidal intent,
and somatic symptoms of fatigue, eating, sleeping and
psychomotor disturbances. The frequencies of dysthy-
mia and DD-NOS also declined, while a slight increase
was seen in the frequency of MDD in the older age
group.
Depressed mood, initial insomnia, disturbed concen-
tration, worthlessness and excessive guilt were all sig-
nificantly related to suicidal acts in all the three bivariate
profiles. In contrast, mood worsening in the evenings,
terminal insomnia, weight loss and gain and both aspects
of psychomotor disturbances were conspicuously absent
from the three bivariate profiles.
Depressed mood has been found to be linked to
suicidality among adolescents in earlier studies (Bettes
and Walker, 1986; Ivarsson et al., 1998). To date, initial
insomnia has been related to suicidal acts only among
adults (Bulik et al., 1990). Our findings extend this
knowledge to a sparsely explored but important area, i.e.,
relationships between suicidal acts and initial insomnia
among adolescents. The cross-sectional model of the
older adolescents revealed a clear trend in sleep dis-
turbances, with five out of the six possible sleep
disturbances (except for terminal insomia) highly
significantly associated with suicidal acts. This finding
could be considered important in the light of recent
findings on the close association between insomnia and
completed suicides among adults (McGirr et al., 2007).
However, similar to other reports among adults, further
analysis (not presented here) showed that these sleep
disturbances were primarily explained by the presence of
depressive disorders (Bernert et al., 2005). Although
decreased appetite and weight loss have been reported
among suicidal adults (Bulik et al., 1990), this finding
was not supported by our study.
In the multivariate models, core cognitive depressive
symptoms known to be associates or predictors of suicidal
acts among adults, i.e., recurring thoughts of death,
suicidal thoughts, worthlessness, hopelessness and dis-
turbed concentration, were found to be associates or
predictors of suicidal acts among adolescents. However,
these relationships were not similar or uniform in their
impact, i.e., they were time-limited and age-specific in
their relationship to suicidal acts. Somewhat surprisingly,
increased appetite and initial insomnia between the ages
of 15 to 20 years were found to be protecting against
suicidal acts, with unclear interpretation.
Two longitudinal studies have reported hopelessness
to be an associate, but not a predictor of suicidal phe-
nomena (Pfeffer et al., 1988; Shahar et al., 2006), as
found in the present study. Although higher levels of
hopelessness have predicted suicide among adult in-
patients and outpatients (Beck et al., 1990; Grøholt
et al., 2006), a similar trend was not found in the present
study of attempted suicide among depressed school
adolescents. The role of hopelessness, diagnostically
assessed by interviews, among suicidal adolescents
appears to be different from its role among adults, as
measured by a questionnaire for the preceding week, in
that it was an associate but not a predictor, in the present
study. Hopelessness has also been found to be an even
stronger predictor of suicidal behaviour than depression
and the best predictor of completed suicide in adult
populations (Beck et al., 1974). A study on whether
Beck's cognitive theory of depression and hopelessness
also applied to adolescent community populations found
support for his theory of depression but not for hope-
lessness (Lewinsohn et al., 2001b). Exploratory research
90 L. Nrugham et al. / Journal of Affective Disorders 111 (2008) 8393
into whether there are three distinct negative thoughts
in the cognitive triad among adults has reported that
there was only a singular one-dimensional negative view
of the self (McIntosh and Fischer, 2000).
Worthlessness, a part of the cognitive triad, by the
age of 15 years, was a significant multivariate predictor
of suicidal acts in the present study. In a study of
children and adolescents with various forms of suicid-
ality, worthlessness has been related to all forms of
suicidal behaviours, after adjustment for other depres-
sive symptoms, comorbid disorders and demographics
(Liu et al., 2006). In the present study, a cross-check
revealed that suicidal acts by 15 years as predictor was
not retained in the model, while worthlessness con-
tinued to be a significant predictor. In the same sample,
that adolescents with suicidal acts had significantly
lower mean scores on self-esteem than participants
without suicidal acts, though the differences were small
and age-dependent (Nrugham et al., 2008). Self-
criticism has been reported to be the cognitive variable
most strongly associated with hopelessness among
adolescent suicide attempters than other depressive
cognitions and perfectionism (Donaldson et al., 2000).
Apart from self-harm without suicidal intent and initial
insomnia, the other depressive symptoms retained in the
final multivariate analyses were all cognitive in nature,
across age and time. These findings underline the
importance of cognitive depressive symptoms as indica-
tors of suicidal acts from adolescence to early adulthood.
Cognitive rigidity is accepted as patently implicated in
suicidal phenomena among adolescents (Beautrais et al.,
1999) and in adults (Arffa, 1983). Although we did not
find suicidal thoughts to be a significant predictor of
suicidal acts, it has been reported that 15-year olds with
suicidal thoughts were 12 times more likely to have
attempted suicide between 15to 30 years of age than those
without suicidal thoughts (Reinherz et al., 2006).
Our finding of self-harm without suicidal intent as a
significant bivariate associate for both age groups and
multivariate associate in the younger age group but not a
bivariate predictor in the older group indicates that acts
of self-harm without suicidal intent decreased with in-
creased age or that acts of self-harm without suicidal
intent had a limited role vis-à-vis suicidal acts in this
sample. Here, it was both, age-specific and time-limited
in its effects. A history of suicidal acts by 15 years,
although an important bivariate predictor, was not
retained in the multivariate model.
While the relationships between dysthymia, DD-
NOS and suicidal acts across adolescence differed with
age and time, MDD was both, a significant associate,
irrespective of age and a significant predictor of suicidal
acts, in the bivariate analyses. However, MDD did not
continue to be significant, neither as an associate nor as
a predictor when compared with depressive symptoms
in the final multivariate analyses of the older adoles-
cents. Dysthymia by 15 years remained a significant
predictor of suicidal acts performed between 15 to
20 years. This is in line with findings among adult
outpatients (Klein et al., 2000). Since cognitive
symptoms dominated the bivariate and multivariate
models it seems that it is not depressive disorders but
specific types of depressive symptoms, i.e., cognitive
depressive symptoms, which are primarily related to
suicidal acts across adolescence. The continuity of
percentages of depressive symptoms and changes in the
distribution of diagnoses as assessed at T3 among the T2
high scorers on the MFQ provide support for the
conceptualization of depression as a continuous variable
and calls to add dimensional criteria to categorical
definitions of diagnosis (Helzer et al., 2006; Pickles and
Angold, 2003; Regier, 2007).
4.1. Limitations
Due to the small number of males in the subset, the
present findings can primarily be generalized to female
adolescents and young adults. At the five-year follow-
up, 30% of the high school adolescents who had been
interviewed at T2 could not be re-interviewed, which
might be an indicator of bias. The analysis of differences
between the participants and non-participants at T3, and
the use of categorical definitions also point to possible
underestimation of the relationships between suicide
attempts and the explanatory variables.
Even though semi-structured diagnostic interviews
were used to obtain information leading to diagnoses
and parents were available as additional informants at
T2, such information is subject to recall bias since it was
retrospective in nature, except for current diagnoses. It
should be noted that information on past and current
symptoms/disorders among school adolescents were
pooled, and was restricted to the most serious episode.
Information regarding other psychiatric symptoms and
disorders at the first interview, T2, was also limited
to symptoms and disorders comorbid with depressive
disorders.
The multivariate models derived in the present study
need to be interpreted with caution. The Hosmer and
Lemeshow statistic was significant for both the multi-
variate predictor models and the final model for older
adolescents indicating poor model calibration. Two of
the associates for the older adolescents had wide
confidence intervals for ORs indicative of low sample
91L. Nrugham et al. / Journal of Affective Disorders 111 (2008) 8393
size. Overall, the associative models were seen to be
better than the predictive models.
However, this study has substantial strengths in its use
of a longitudinal design covering most of the adolescent
period into early adulthood. The present subset of
adolescents was selected from a school-based representa-
tive sample using a case-control design with an over-
inclusion of depressed adolescents, thus enabling us to
assess the effects of various diagnoses of depression on
suicidality with increased power, in addition to the use of
blind and randomized diagnostic interviews by clinicians
with excellent interview integrity. Together, the over-
sampling of depressed adolescents at 15 years of age and
the inclusion of only clinically significant symptoms,
makes the adolescents in the present study resemble the
adolescent outpatient population.
4.2. Conclusions
Future research should aim to replicate the findings of
the present study, with special focus on cognitive
depressive symptoms in adolescence and integrating
categorical and dimensional approaches. Any depressive
disorder, self-harm without suicidal intent in younger
adolescents, middle insomnia in older adolescents and
cognitive depressive symptoms irrespective of age,
should alert school mental health professionals and
clinicians in their assessment of suicidalilty among
adolescents.
Role of funding source
The funding sources The Norwegian Research Council, Council
for Mental Health, Child and Adolescent Mental Health Clinic,
Trondheim and the Regional Centre for Child and Adolescent Mental
Health, Central Norway have had no role in the planning of the study
design; collection, analysis and interpretation of data; in writing the
report or in the decision to submit the paper for publication.
Conflict of interest
All authors declare that they have no conflict of interest.
Acknowledgement
This research was supported in part by grants from
the Norwegian Research Council, Council of Mental
Health, Regional Centre for Child and Adolescent
Mental Health, Central Norway and the Child and
Adolescent Mental Health Clinic, Trondheim. The
valuable contribution and help from the participating
adolescents, youth, parents and school and project staff,
is gratefully acknowledged. The authors gratefully
acknowledge Prof. Berit Grøholt for her valuable
comments on the manuscript.
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... Importantly, many do not control for other depressive symptoms (i.e., depression severity) or other well-established risk factors such as suicide attempt history. To our knowledge, only two studies have examined the predictive relationships between multiple specific depressive symptoms and future suicide attempts in adolescents, both of which were conducted in community samples (Busby Grant et al., 2023;Nrugham et al., 2008). Nrugham and colleagues (2008) found that depressed mood, worthlessness, and excessive guilt most strongly predicted future attempts. ...
... Thus, adolescents who are more vulnerable to experiencing sleep disturbances during times of high emotional stress (e.g., IOP entry) may (increased motor function) and cognitive (painful mental arousal). Regarding weight/appetite, Nrugham (2008) similarly did not find significant contribution to attempt. However, Busby Grant and colleagues' study (2023) showed an association between reduced appetite and future attempt. ...
... Two symptoms of depression -psychomotor disturbance and weight/appetite change -were not associated with future suicide attempts, even at the bivariate level. Nrugham (2008) and Busby Grant (2023) similarly did not find significant bivariate associations between psychomotor agitation or slowing and future attempt in community adolescents. A recent meta-analysis (Rogers et al., 2016) found a moderate association between suicidal behavior and agitation. ...
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Depression is a risk factor for suicide attempt, but its ability to differentiate individuals at heightened risk as a total score falls short. Prospective investigations of individual depressive symptoms in relation to adolescent suicide attempt are limited and seldom control for established risk factors such as attempt history and other depressive symptoms. Participants (n = 854) were suicidal adolescents enrolled in intensive outpatient treatment targeting suicidality. Depressive symptoms (composite measures of mood, sleep, appetite/weight, and psychomotor disturbance, as well as single-item measures of disturbed concentration, negative self-appraisal, suicidal ideation (SI), anhedonia, and low energy) were measured at entry. Suicide attempts between treatment entry and six months after discharge were recorded (n = 156; ‘future attempters’). Bivariate comparisons found significant differences between future attempters and non-attempters on all depressive symptoms besides appetite/weight and psychomotor disturbances. Logistic regression showed that only sleep disturbance and SI contributed to future attempt while controlling for age, sex, attempt history, and other depressive symptoms. A subsequent model revealed that middle and late insomnia largely accounted for sleep’s relationship with future attempt. Age, attempt history, and SI were significant predictors in both models. Difficulty with maintaining sleep, early morning awakenings, and severe SI might signal an additional warning for proximate suicide attempt, particularly in youth with attempt history. These results support the measurement of deconstructed depressive symptoms as a practical addition to risk assessment for clinicians managing suicidal adolescents. Such specific risk indicators might signal the need for more intensive care and closer post-discharge monitoring.
... Suicide is a public health issue and one of the leading causes of mortality among the adolescent population [1], being the third cause of death in people aged [10][11][12][13][14][15][16][17][18][19] in Spain [2]. The characteristics of suicide in adolescents differ from adults, as psychological and social risk factors seem to play an important role in addition to biological factors [3]. ...
... The presence of mental health disorders is one of the main risk factors of suicide in adolescents. Several studies have linked depression with an increased risk of ideation and suicide attempt in adolescents [11,12], as well as other disorders such as anxiety disorders, personality disorders, and post-traumatic stress disorder [13]. Externalizing disorders, such as attention deficit hyperactivity disorder and conduct disorders, have been suggested to be more specific suicidal risk factors for children and adolescents [14,15], while the presence of psychiatric comorbidities would confer a greater risk of suicidal behavior [16,17]. ...
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Unlabelled: The COVID-19 pandemic is having a major impact on the mental health of adolescents, leading to suicidal behaviors. However, it remains to be clarified whether the COVID-19 pandemic has changed the psychiatric profile of adolescent suicide attempters. Methods: a retrospective observational analytical study was conducted to assess age, gender and clinical characteristics of adolescents attempting suicide during the year before and the year after the global lockdown. Results: ninety adolescents (12-17 y.o.) were recruited consecutively from February 2019 to March 2021 at the emergency ward for having attempted suicide. Fifty-two (57.8%) attended before the lockdown (pre-pandemic group) and thirty-eight (42.2%) the year after (pandemic group). There were significant differences in diagnostic categories between the periods (p = 0.003). Adjustment and conduct disorders were more frequent in the pre-pandemic group, while anxiety and depressive disorders were more prevalent during the pandemic. Although the severity of suicide attempts did not show significant differences between the two study periods (0.7), the generalized linear model showed that the suicide attempt severity was significantly associated with current diagnosis (p = 0.01). Conclusions: the psychiatric profile of adolescents attempting suicide was different before and during the COVID-19 pandemic. During the pandemic, the proportion of adolescents with a prior psychiatric history was lower, and most of them were diagnosed with depressive and anxiety disorders. These diagnoses were also associated with a greater severity in the intentionality of suicide attempt, regardless of the study period.
... Insomnia in adolescents affects physical-and mental-health as well as quality of life. It has been suggested that insomnia in early adolescence may initiate development of depressive symptoms over time [65,66]. Prevalence of depression in this cohort was estimated 27.7% and significantly more prevalent in females (36.2%) compared to males (5.6%), as others have reported [67]. ...
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Objectives Sleep is often compromised in adolescents, affecting their health and quality of life. This pilot-study was conducted to evaluate if implementing brief-behavioral and sleep-hygiene education with mindfulness intervention may positively affect sleep-health in adolescents. Method Participants in this community-based non-randomized cohort-study volunteered for intervention (IG)- or control-group (CG). Sleep was recorded during regular school-schedule for 3-school-nights and 2-non-school-nights with an FDA-cleared/EU-Medical Device Regulation (CE-2862) compliant home sleep test, and Questionnaires were utilized to evaluate chronotype, sleepiness, insomnia-, anxiety- and depression-symptoms. The four-week intervention included sleep-hygiene education, mindfulness- and breathing-practices for one-hour, twice weekly. Data was collected during the last-week of February and first two-weeks of March 2023 and repeated after intervention. Results Fifty-five participants completed the study, IG (86%) and CG (77%). Average age was 17.3-years and prevalence of severe social-jetlag (SJL) 72%. Participants who quit participation (n = 10) after baseline data-collection all females (3-IG/7-CG) in comparison to participants who completed the study were sleepier than the IG and CG (+ 2.6-p = 0.04; + 3.8-p = 0.001), with more symptoms of insomnia- (+ 3.8-p = 0.002; + 4.7-p < 0.0001), and depression (+ 16.7-p < 0.0001; + 19.6-p < 0.0001), and report being later-chronotypes, (-18.2, p < 0.0001;-13.1, p < 0.0001). On average the IG advanced sleep-onset (32-min; p = 0.030), decreased SJL (37-min; p = 0.011) and increased total sleep time (TST, 29-min; p = 0.088) compared to the CG. Average sleep duration did not differ significantly comparing IG and CG after intervention. Stratifying participants with severe SJL (> 2-h) at baseline; 1) responders (61%) advanced sleep-onset on non-school-nights (96-min) and decreased SJL (103-min; p < 0.001) 2) non-responders (39%) increased sleep-duration on school-nights (36-min) and non-school-nights (63-min) but maintained severe-SJL. Conclusion Teacher-lead sleep-education and mindfulness program can improve TST and SJL in adolescence.
... Comorbidity with other psychopathological conditions, especially anxiety and substance use disorders, is common (Galaif et al., 2007;Lai et al., 2015). Depression is closely associated with suicide (Hetrick et al., 2012;Nock et al., 2008a;Nrugham et al., 2008). Suicide is the number one cause of death for young Australians (Australian Institute of Health and Welfare, 2021) and is the fourth leading cause of death for young people globally (World Health Organization, 2021). ...
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Objective: Depression and suicidal ideation are closely intertwined. Yet, among young people with depression, the specific factors that contribute to changes in suicidal ideation over time are uncertain. Factors other than depressive symptom severity, such as comorbid psychopathology and personality traits, might be important contributors. Our aim was to identify contributors to fluctuations in suicidal ideation severity over a 12-week period in young people with major depressive disorder receiving cognitive behavioural therapy. Methods: Data were drawn from two 12-week randomised, placebo-controlled treatment trials. Participants (N = 283) were 15-25 years old, with moderate to severe major depressive disorder. The primary outcome measure was the Suicidal Ideation Questionnaire, administered at baseline and weeks 4, 8 and 12. A series of linear mixed models was conducted to examine the relationship between Suicidal Ideation Questionnaire score and demographic characteristics, comorbid psychopathology, personality traits and alcohol use. Results: Depression and anxiety symptom severity, and trait anxiety, independently predicted higher suicidal ideation, after adjusting for the effects of time, demographics, affective instability, non-suicidal self-injury and alcohol use. Conclusions: Both state and trait anxiety are important longitudinal correlates of suicidal ideation in depressed young people receiving cognitive behavioural therapy, independent of depression severity. Reducing acute psychological distress, through reducing depression and anxiety symptom severity, is important, but interventions aimed at treating trait anxiety could also potentially be an effective intervention approach for suicidal ideation in young people with depression.
... Guilt or negative self-referential thinking has been implicated in the onset and maintenance of depression (Dainer-Best et al., 2017;Hards et al., 2020) and suicidality among adolescents (Nrugham et al., 2008;Sekowski et al., 2020). The emergence of guilt as a central symptom in the network of our adolescent sample, and its close connection with suicidality in the flow network is consistent with the findings among for depressed adolescents in Sub-Saharan Africa (Osborn et al., 2020) and North America (Mullarkey et al., 2019). ...
Article
Background: Persons with suicidality including suicidal ideation (SI), suicide plans (SP) and/or suicide attempts (SA) are at higher risk for future suicide than those without suicidality. To reduce risk of future suicide, it is important to understand symptoms of emotional distress having the strongest links with SI, SP and SA. This network analysis examined item-level relations of depressive and anxiety symptoms with suicidality among adolescents during the COVID-19 pandemic. Methods: Adolescents between 12 and 20 years of age were assessed with the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and individual binary reponse (no/yes) items assessing SI, SP, and SA during the pandemic. The structure of depressive symptoms, anxiety symptoms and suicidality was characterized using "Expected Influence" and "Bridge Expected Influence" as centrality indices in the symptom network. Network stability was tested using a case-dropping bootstrap procedure. Node-specific predictive betweenness was computed to examine short paths of anhedonia, other depressive symptoms and anxiety symptoms with suicidality. A Network Comparison Test (NCT) was conducted to examine whether network characteristics differed based on gender. Results: Prevalence rates of depressive symptoms, anxiety symptoms, and suicidality were 44.60 % (95%CI = 41.53-47.67 %), 31.12 % (95%CI = 28.26-33.98 %), and 16.95 % (95%CI = 14.63-19.26 %), respectively, in the study sample. The network analysis identified GAD3 ("Worry too much") as the most central symptom, followed by GAD6 ("Irritability") and PHQ6 ("Guilt") in the sample. Additionally, PHQ6 ("Guilt"), GAD6 ("Irritability"), and PHQ2 ("Sad mood") were bridge nodes linking depressive and anxiety symptoms with suicidality. A flow network indicated that the connection between S ("Suicidality") and PHQ6 ("Guilt") reflected the strongest connection, followed by connections of S ("Suicidality") with GAD2 ("Uncontrollable worrying"), and S ("Suicidality") with PHQ2 ("Sad mood"). Finally, PHQ2 ("Sad mood") was the main bridge node linking anhedonia with other depressive and anxiety symptoms and suicidality in the sample. Conclusions: Findings highlight the potential importance of reducing specific depressive and anxiety symptoms as possible means of reducing suicidality among adolescents during the pandemic. Central symptoms and key bridge symptoms identified in this study should be targeted in suicide prevention for at risk adolescents.
... The underlying mechanism of the association between depression and suicide is complex, including the synergic effects of psychosocial stressors, genetics, monoaminergic neurotransmitters, and other neuromodulators (Orsolini et al., 2020). Many symptoms included in the diagnostic criteria of depressive disorders are associated with increased suicidal risks, including concentration deficit, poor sleep, low self-esteem, worthlessness, and negative inferential style (Burke et al., 2016;Nrugham, Larsson, & Sund, 2008). Anhedonia, also known as the inability to experience pleasure, is greater among adolescent suicide attempters than suicidal ideators or control (Auerbach, Millner, , & Esposito, 2015), and is predictive of subsequent suicidal events (Yen et al., 2013). ...
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Background Youth suicide rates have increased markedly in some countries. This study aimed to estimate the population-attributable risk of psychiatric disorders associated with suicide among Taiwanese youth aged 10–24 years. Methods Data were obtained from the National Death Registry and National Health Insurance (NHI) claims database between 2007 and 2019. Youth who died by suicide were included, and comparisons, 1:10 matched by age and sex, were randomly selected from the Registry for NHI beneficiaries. We used multivariable logistic regression to estimate suicide odds ratios for psychiatric disorders. The population-attributable fractions (PAF) were calculated for each psychiatric disorder. Results A total of 2345 youth suicide and 23 450 comparisons were included. Overall, 44.8% of suicides had a psychiatric disorder, while only 7.9% of the comparisons had a psychiatric disorder. The combined PAF for all psychiatric disorders was 55.9%. The top three psychiatric conditions of the largest PAFs were major depressive disorder, dysthymia, and sleep disorder. In the analysis stratified by sex, the combined PAF was 45.5% for males and 69.2% for females. The PAF among young adults aged 20–24 years (57.0%) was higher than among adolescents aged 10–19 years (48.0%). Conclusions Our findings of high PAF from major depressive disorder, dysthymia, and sleep disorder to youth suicides suggest that youth suicide prevention that focuses on detecting and treating mental illness may usefully target these disorders.
Article
The prevention paradox describes circumstances in which the majority of cases with a suicide attempt come from a population of low or moderate risk, and only a few from a ‘high-risk’ group. The assumption is that a low base rate in combination with multiple causes makes it impossible to identify a high-risk group with all suicide attempts. The best way to study events such as first-time suicide attempts and their causes is to collect event history data. Administrative registers were used to identify a group at higher risk of suicidal behaviour within a population of six national birth cohorts (N = 300,000) born between 1980 and 1985 and followed from age 15 to 29 years. Estimation of risk parameters is based on the discrete-time logistic odds-ratio model. Lifetime prevalence was 4.5% for first-time suicide attempts. Family background and family child-rearing factors were predicative of later first-time suicide attempts. A young person’s diagnosis with psychiatric or neurodevelopmental disorders (ADHD, anxiety, depression, PTSD), and being a victim of violence or sex offences contributed to the explanatory model. Contrary to the prevention paradox, results suggest that it is possible to identify a discrete high-risk group (<12%) among the population from whom two thirds of all first-time suicide attempts occur, but one third of observed suicide attempts derived from low- to moderate-risk groups. Findings confirm the need for a combined strategy of universal, targeted and indicated prevention approaches in policy development and in strategic and practice responses, and some promising prevention strategies are presented.
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The present study explored the association between adolescents’ perceived parental relationship and their depressive symptoms, as well as the mediating effect of self-compassion and the moderating effect of school connectedness. The present cross-sectional study draws upon data procured from a sample of 6,801 adolescents in junior high schools located in Shenzhen, China. The data were collected in December 2021, marking a year since the outbreak of the pandemic. The parents’ marital relationship, adolescents’ depressive symptoms, self-compassion and school connectedness were measured by adolescents’ self-reported questionnaires. The mediating and moderated mediating models were computed using Mplus 8.0 with bootstrapping method. The results revealed that, after controlling age and gender, (1) marital relationship negatively predicted adolescents’ depressive symptoms; (2) adolescents’ self-compassion partially mediated the association between parental relationship and depressive symptoms; (3) school connectedness moderated the link between marital relationship and self-compassion as well as the link between the marital relationship and depressive symptoms; and (4) parents’ marital relationship has a stronger affect on self-compassion for girls than boys, and girls’ self-compassion exerts a slightly stronger influence on depressive symptoms than boys. The findings illuminated that it is of great importance to cultivate adolescent self-compassion and school connectedness, which may block or buffer the effect of poor martial relationship on adolescent depressive symptoms. Moreover, a good sense of school connection may be particularly important in protecting mental health of adolescents whose parents have poor marital relationships.
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Objective: We investigated the differences in suicidality between young people and older adults with depression over the course of 12-week naturalistic treatment with antidepressants. Methods: A total of 565 patients who had moderate to severe depression (Hamilton Depression Rating Scale [HAM-D] score ≥14) and significant suicidal ideation (Beck Scale for Suicide Ideation [SSI-B] score ≥6) were recruited from 18 hospitals. Participants were classified into two groups: the younger group (13-24 years of age, n=82) and the older group (≥25 years of age, n=483). Total scores over time on the SSI-B, HAM-D, and Hamilton Anxiety Rating Scale (HAM-A) were assessed and compared between the two groups. Results: At baseline, the younger group had lower HAM-D scores (21.0 vs. 22.2; p=0.028) but higher SSI-B scores (19.4 vs. 15.6; p<0.001) compared with the older group. The overall 12-week proportion of patients with resolved suicidality was 44.1% in the younger group and 69.2% in the older group. Although the improvement in the HAM-D and HAM-A scores did not differ between the groups, suicidal ideation in the younger group remained more severe than in the older group throughout the treatment. The ratio of the subjects who achieved HAM-D remission or response but did not achieve SSI-B remission was significantly higher in the younger group than in the older group. Conclusion: These data suggest that in depressed youths, suicide risk is a serious concern throughout the course of depression even when favorable treatment outcomes are obtained.
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An array of psychosocial risk factors for making a suicide attempt were examined in a representative sample of 1,508 older (14- to 18-year-old) high school students, 26 of whom made a suicide attempt during the year following entry into the study. Strongest predictors of future suicide attempt were history of past attempt, current suicidal ideation and depression, recent attempt by a friend, low self-esteem, and having been born to a teenage mother. The results suggest that adolescents who are depressed and those who attempt suicide share many psychosocial risk factors. The efficacy of two screeners (one consisting of 4 items and the other of 6 variables) is reported. Potential usefulness for research and communitywide prevention is discussed.
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Examined the factorial validity of the cognitive triad (view of self, world, and future) hypothesized by A. T. Beck (1987) to be a key depression-related variable. A nonclinical sample of 641 university undergraduates completed the Cognitive Triad Inventory (CTI). Although an initial confirmatory factor analysis failed to support a 3-factor model for the CTI drawn from Beck's paradigm, a principal components analysis yielded a single factor which was labeled, "Self-Relevant Negative Attitude." Additional analyses confirmed the viability of the 1-factor solution and showed that the CTI was still a reliable scale with 12 as opposed to the original 30 items. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Objective: The purpose of this study was to examine whether suicidal ideation in a community population of adolescents represents normative adolescent angst or is predictive of psychopathology, suicidal and problem behaviors, and compromised functioning 15 years after onset. Method: Participants were 346 largely Caucasian individuals who were part of a single-age cohort from a working class community and whose development had been traced prospectively from ages 5 to 30. Those with suicidal ideation at age 15 were compared to those without suicidal ideation at age 15 on measures of psychopathology, suicidal ideation and behavior, problem behaviors, and adult functioning at age 30. Gender differences were assessed across all domains. Results: At age 30, there were marked differences between adolescents with suicidal ideation and adolescents without suicidal ideation of both genders in most domains examined. Subjects with suicidal ideation were twice as likely to have an axis I disorder, nearly 12 times more likely to have attempted suicide by age 30, and 15 times more likely to have expressed suicidal thoughts in the past 4 years. Subjects with suicidal ideation had more problem behaviors and poorer overall functioning as assessed by multiple informants. Their self-perceptions of coping ability, self-esteem, and interpersonal relations were also lower. Although subjects with suicidal ideation among both genders had higher levels of psychopathology, suicidal ideation and behavior, and problem behaviors at age 30, male subjects with suicidal ideation had lower salaries and socioeconomic status and were less likely to have achieved residential independence. Conclusions: Findings underscore the importance of considering suicidal ideation in adolescence as a marker of severe distress and a predictor of compromised functioning, indicating the need for early identification and continued intervention.
Chapter
IntroductionEpidemioliogy of Suicidal BehaviourSuicide Risk and Protective FactorsPrevention of Suicidal BehaviourReferences
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• We evaluated the Children's Global Assessment Scale (CGAS), an adaptation of the Global Assessment Scale for adults. Our findings indicate that the CGAS can be a useful measure of overall severity of disturbance. It was found to be reliable between raters and across time. Moreover, it demonstrated both discriminant and concurrent validity. Given these favorable psychometric properties and its relative simplicity, the CGAS is recommended to both clinicians and researchers as a complement to syndrome-specific scales.
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This chapter provides an update of the growing body of empirically based knowledge about adolescent suicidal behavior. After reviewing findings on the incidence and prevalence of adolescent suicidal thoughts and behaviors, the author discusses information pertinent to the understanding of the continuum of adolescent suicidality. The links between adolescent suicidal behavior and psychopathology, particularly identifiable psychiatric disorders, as well as critical parental, family system, and life event influences are then discussed. An argument is made for the further integration of theory and empirical research. A developmental model is offered that suggests pathways in suicidal behavior among depressed adolescents with comorbid alcohol/substance abuse. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Abstract This study followed up into adulthood a group of child psychiatric patients suffering from depressive disorders and a closely matched nondepressed child psychiatric control group. Depression in childhood was a strong predictor of attempted suicide in adulthood. This predictive power was not due to the association between childhood depression and other childhood risk factors such as conduct disorder or suicidality. Rather, it seemed mostly to reside in the association between depression in childhood and major depression in adult life. These findings suggest that the pathways from childhood psychopathology to adult outcomes can be complex, and depend crucially on what happens later.
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This article reviews the literature related to studies measuring various cognitive properties in suicidal patients. It provides a structural framework with which to classify the studies, and employs the categories of suicidal logic, cognitive style, social cognition, and cognitive control. The methodological issues discussed include: sample characteristics, operational definitions of suicidal behaviors, use of appropriate control groups, and the temporal nature of assessment. Improvements in experimental design are suggested for use in future research.