Research paperProximally-occurring life events and the first transition from suicidal ideation to suicide attempt in adolescents
Introduction
Suicide is currently the third leading cause of death in U.S. adolescents (Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control, 2017). Risk for death by suicide is often conceptualized as occurring on a continuum of severity from passive death wishes to suicidal ideation, planning, and attempt, with a prior suicide attempt being the most robust risk factor for suicide death (Ribeiro et al., 2016). Because only approximately one-third of adolescents who have thought about suicide will progress to a suicide attempt, increasing attention has been paid to identifying factors which discriminate these two groups of adolescents (Glenn and Nock, 2014, Nock et al., 2013). Factors posited by diathesis stress models of suicide risk to increase this progression include aggression, impulsivity (Bridge et al., 2006, Hawton et al., 2012, O'Connor et al., 2012), and interpersonal loss or discord (Bridge et al., 2006). Dating violence victimization and self-injury (Taliaferro and Muehlenkamp, 2014) and the suicidal behavior of others (Dhingra et al., 2015, Mars et al., 2018, O'Connor et al., 2012) have been found to empirically distinguish these two groups of adolescents.
However, when adolescents are asked directly about the most important trigger for their suicide attempt, the most common reasons given are conflicts with parents and romantic partners which had been recently been escalating (Dieserud et al., 2010) and family relationship problems (Hawton and Harriss, 2008, Jacobson et al., 2013, Rice and Tan, 2017), while mental health concerns rank second (Dieserud et al., 2010). Previous research also shows that adolescents who have attempted suicide report more negative life events than control groups (Liu and Miller, 2014). Fewer studies have directly examined how interpersonal stressors distinguish adolescents with suicidal ideation from those who attempt. For example, stressful life events in the past 12 months distinguished adolescents who had recently (past 6 months) progressed to a suicide attempt from those with ideation only (King et al., 2001). However, analyses did not account for covariates. In their large multi-country study of European secondary school students, Madge et al. (2011) found that adolescents who had engaged in past-year self-harm (including intentional overdose and other methods typically deemed to be “suicide attempts”) were distinguished from those who had only thought of self-harm by past year life events of physical abuse or sexual abuse, sexual orientation concerns, and knowing someone who had self-harmed or committed suicide. Given the stated importance of interpersonal conflicts for suicide attempts from adolescents’ own perspectives, a deeper understanding of the circumstances which influence the transition from suicidal ideation to an attempt is needed.
Diathesis-stress models of suicide risk specify several underlying vulnerabilities (Bridge et al., 2006, Brodsky, 2016, Mann et al., 1999) which may interact with recent stressful life events to increase the likelihood of transitioning to a suicide attempt. However, few empirical tests of the interactions of these factors have been carried out and results have been mixed. In their longitudinal sample of inpatient adolescents, Daniel et al. (2016) unexpectedly reported that the association of major loss life events in the prior 3 months with subsequent suicide attempts increased when levels of depressive symptoms were low. However, aggression and impulsivity, key vulnerabilities for transitioning from ideation to an attempt (Hawton et al., 2012, O'Connor et al., 2012) in adolescents, were not assessed. Similarly, a clinical study of adults reported that the presence of a current major depressive episode (MDE) did not influence the relationship between the number of recent stressful life events and a suicide attempt (Oquendo et al., 2014). Bagge et al. (2013) also found that in their clinical sample of adults, alcohol problems, drug problems, or borderline personality disorder (BPD) diagnosis neither increased nor decreased the likelihood of a negative life event triggering a suicide attempt. These findings conflict with what is posited by leading theories of suicide risk, namely, that recent stressors should combine with vulnerabilities such as a depressive disorder and impulsive aggression (Brodsky, 2016). More research in adolescent samples is also needed.
This research paper examines proximally-occurring relational conflicts and life stressors which increase the likelihood of transitioning from thinking about suicide to a first attempt. First, it is expected that a greater number of recent stressful life events (King et al., 2001) and interpersonal life stressors involving loss and conflict, particularly in the family (Dieserud et al., 2010, Rice and Tan, 2017), will discriminate these two groups of adolescents. Conversely, negative life events in the past year that do not involve disruptions and serious problems in close interpersonal relationships will not associate with this transition. Second, among adolescents with lifetime suicidal ideation, the presence of a psychiatric disorder, particularly those involving substance use, impulsivity, and aggression, will potentiate the risk for past year interpersonal stressors in transitioning to a first suicide attempt.
Section snippets
Data
Data are from the National Comorbidity Survey- Adolescent Supplement (NCS-A). The NCS-A is nationally representative survey of adolescents ages 13–18 in the United States (N = 10,148) (Kessler et al., 2009). The NCS-A used a dual-frame sampling procedure composed of: (a) a household sub-sample of adolescents (n = 904) selected from NCS-R households, and (b) a school sub-sample of adolescents (n = 9244) selected from schools in the same nationally representative counties as those in the NCS-R.
Descriptive statistics
Bivariate differences in all study variables between adolescents with lifetime suicidal ideation and no suicide attempt versus those with a past year first suicide attempt are presented in Table 1. Four covariates significantly distinguished these two groups of adolescents: gender, age, family income, and parental education. As expected, female adolescents were more than twice as likely as males (Odds Ratio (OR) = 2.64; 95% Confidence Interval (CI) = 1.50–4.65) to have transitioned from
Discussion
The aim of this study was to better understand the role of proximally-occurring stressful life events in the transition from suicidal ideation to a first suicide attempt in adolescence. Adolescents who had made this progression in the past year were distinguished from their peers with suicidal ideation only by a greater number of recent interpersonal stressors and a romantic break-up. The former finding extends the work of King et al. (2001) by showing that more recent stressful life events
Conclusions
Relational conflicts are consistently the most commonly cited precipitant for suicide attempts in adolescents (Rice and Tan, 2017). Treatment and clinical assessment of suicidal adolescents would therefore benefit from inquiring about adolescents’ individual needs regarding these conflicts (Dieserud et al., 2010). The life events most strongly associated with the transition to suicide attempt from suicidal ideation were seemingly commonplace events such as romantic relationship break-ups and
Contributors
Dr. Paul was the sole author of the paper and takes full responsibility for the integrity of the analyses and content.
Role of the funding source
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
The author declares no conflicts of interest.
Declarations of interest
None.
Acknowledgments
The data used in this publication were made available by the National Comorbidity Survey-Adolescent (NCS-A) Supplement and have been used with permission. The NCS-A data were originally collected by Ronald C. Kessler and the NCS-A research team. The author thanks John Eckenrode, Ph.D, Gary W. Evans, Ph.D, and Maureen Waller, Ph.D, of Cornell University for their helpful comments on this paper. The author also thanks the adolescents who participated in the NCS-A study.
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