ADOLESCENT SUICIDAL IDEATION.

Field, Tiffany ; Diego, Miguel ; Sanders, Christopher E. 等

ABSTRACT

Adolescent suicidal ideation and its relationship to other variables was tapped by a self-report questionnaire administered to 88 high school seniors. Eighteen percent responded positively to the statement "sometimes I feel suicidal." Those who reported suicidal ideation were found to differ from those who did not on a number of variables, including family relationships (quality of relationship with mother, intimacy with parents, and closeness to siblings), family history of depression (maternal depression), peer relations (quality of peer relationships, popularity, and number of friends), emotional well-being (happiness, anger, and depression), drug use (cigarettes, marijuana, and cocaine), and grade point average. Stepwise regression indicated that happiness explained 48% of the variance in suicidal ideation, and number of friends, anger, and marijuana use explained an additional 20%, for a total of 66% of the variance. While 34% of the variance remained unexplained, it is suggested that the questions used to measure these four variables be included in global screenings to identify adolescents at risk for suicidal ideation.

Suicidal ideation is typically investigated using multivariate models that include the following factors: family relationships, loneliness, anger, depression, and substance abuse (Jacobs, Brewer, & Klein, 1999). In a recent multivariate study of 120 adolescents, discriminant function analyses indicated that high levels of depression and anger expression predicted self-reported wish to die (Boergers, Spirito, & Donaldson, 1998). In a similar study of 374 high school students, social support and depression were significantly related to suicidal ideation levels one year later (Mazza & Reynolds, 1998). The research regarding family relationships has generally focused on social support. Peer relationships have often been overlooked except for the use of loneliness as a variable. In one study, suicidal thinking was found to be related to greater loneliness (Roberts, Roberts, & Chen, 1998). In that study, as in many studies, depression was the strongest factor to emerge in the regression analyses. In fact, in one st udy when the effect of depression was removed, the relationships between suicidal ideation and other correlates weakened or disappeared (De Man, 1999). In longitudinal studies, depression has been found to be the most frequent predictor of subsequent suicidal ideation and attempts, with suicidal ideation and attempts in turn being predictors of subsequent depression (see Fisher, 1999, for a review).

Family history of depression is also a significant risk factor (Brent, Moritz, Liotus, Schweers, Balach, Roth, & Perper, 1998). In particular, this has been noted for maternal depression (Garber, Little, Hilsman, & Weaver, 1998).

As noted, anger is often seen along with depression in adolescents who experience suicidal ideation (Boergers et al., 1998). In one recent study, adolescents who were depressed were at greater risk if they also manifested high levels of anger and aggression (Stein, Apter, Ratzoni, Har-Even, & Avidin, 1998). In another study, adolescent males were found to be at greater risk for suicidality if they were aggressive, and adolescent females were at greater risk if they were depressed (Prigerson & Slimack, 1999).

Gender differences have also been noted for the relationships between depression, substance use, and suicidality. In their model of adolescent suicide risk, Metha, Chen, Mulvenon, and Dode (1998) reported that males progressed from depression to substance use and then to suicide risk, while females progressed directly from depression to suicide risk. Similarly, in a longitudinal study across a 21-year period (1970-1990), detailed analyses of a random sample of 80 psychiatric patients showed that suicidal behavior increased significantly among male adolescents only, and substance misuse correlated with that increase over time (Fombonne, 1998). The rates of both suicidal behavior and substance misuse almost doubled across those years. Family history of substance abuse has also been found to contribute to the risk profile for adolescent suicide (Kosky, Eshkevari, et al., 1998).

The present study examined all of these factors simultaneously using a self-report questionnaire (Field & Yando, 1991). The questionnaire included Likert-scale questions, as well as full standardized scales dealing with family relationships, peer relationships, depression, parental depression, anger, and substance use. Based on the literature, all of these factors were expected to be related to suicidal ideation. In addition, because depression and substance abuse have been associated with diminished academic performance, grade point average was included as a variable. It was hoped that the findings would be useful in formulating a risk profile for adolescents, who then could be screened for suicidal ideation.

METHOD

Participants

Eighty-eight high school seniors (52 females, 36 males) completed the questionnaire. Their mean age was 17.2 years. The ethnic distribution of the sample was 75% Caucasian, 11% Hispanic, 5% Asian, 4% African American, and 5% other. The participants were of middle to upper middle socioeconomic status.

Procedure

The high school seniors were administered the 181-item questionnaire during an English class. The questionnaire included the following single- and multiple-item scales.

Relationship quality with parents/friends (Blyth & Foster-Clark, 1987). This 24-item scale assesses mother, father, and best friend relationships. Questions include the following: "How much does your mother understand what you're really like?" "How much do you go to your father for advice/support?" "How much do you share your inner feelings or secrets with your best friend?" Responses range from 1 = not at all to 5 = very much. Higher scores are optimal. This scale has been reported to have good internal consistency and test-retest reliability (Blyth & Foster-Clark, 1987).

Intimacy with parents. Additional relationship items included (a) conversations with each parent: "How often do you have conversations with your mother (or father)?" (1 = never to 5 = daily) and "How good do you think your conversations are with your mother (or father)?" (1 = onexistent to 5 = very good); (b) touch with each parent: "How often does your mother (or father) hug or show you physical affection?" and "How often do you hug or show physical affection towards your mother (or father)?" (1 = never to 5 = daily); and (c) time spent with family or friends (1 = one hour or less, 2 = two to six hours, and 3 = seven or more hours per week).

Closeness to siblings. Participants rated closeness to brothers and/or sisters on a 5-point Likert scale.

Well-being. Participants responded to the statement "All things considered, my life is going well" on a 4-point Likert scale.

Happiness. Participants rated how they feel about their friends, family, and self on a 4-point Likert scale. The three ratings were then averaged to obtain a composite score.

Anger. Anger was assessed via participants' yes/no response to one statement: "Sometimes I feel so angry that I worry that I will become violent."

Depression. Depression was assessed using the Center for Epidemiological Studies Depression Scale (Radloff, 1991). This scale contains twenty depressive symptoms experienced over the past week (e.g., "I felt lonely"), which are rated on a 4-point Likert scale (0 = rarely or none of the time, 1 = some or a little of the time, 2 = a lot of the time, and 3 = most of the time). This scale has been standardized for high school populations, with a score of 19 or higher indicating depressed mood (Radloff, 1991). Test-retest reliability (.80-.90) and concurrent validity for this scale have been found to be acceptable across a variety of demographic variables, including age, education, and ethnicity (Wells, Klerman, & Deykin, 1987).

Drugs. Participants separately rated previous cigarette, marijuana, and cocaine use on a 4-point Likert scale.

Grade point average. Grade point average (GPA) was used as the measure of academic performance. Participants reported their GPA on a 4-point Likert scale (grades ranging from A to D).

RESULTS

Based on a yes/no response to a question on suicidal ideation, the participants were divided into two groups: those who had experienced suicidal ideation (n = 16, or 18%) and those who had not (n = 72, or 82%). Following significant results from a multivariate test (Hotelling's [T.sup.2]), univariate t tests were conducted to compare the two groups. As can be seen in Table 1, the suicidal ideation group received less optimal scores/ratings on the following: (1) family relationships, including (a) quality of relationship with mother, (b) intimacy with parents, (c) closeness to siblings, and (d) maternal depression; (2) peer relationships, including (a) quality of peer relations, (b) popularity, and (c) number of friends; (3) emotional well-being, including (a) happiness, (b) anger, and (c) depression; (4) use of drugs, including (a) cigarettes, (b) marijuana, and (c) cocaine; and (5) grade point average.

Those variables that differentiated the two groups were then entered into a stepwise regression, with suicidal ideation as the dependent variable. As can be seen in Table 2, the happiness variable accounted for 46% of the variance (R-square). This was followed by number of friends (which accounted for an additional 11% of the variance), anger (5% of the variance), and marijuana use (4% of the variance). Together, these variables accounted for 66% of the variance in suicidal ideation.

DISCUSSION

The two groups of high school seniors (those who experienced suicidal ideation and those who did not) differed on a number of dimensions that are rarely discussed in the literature, including the quality of their family relationships and intimacy with their parents. Family support and maternal depression have received significant attention in the literature and were differentiating factors in this study, confirming previous findings (Garber et al., 1998; Mazza & Reynolds, 1998). Aside from loneliness or isolation, peer relations are also rarely discussed in the literature. Here, the suicidal ideation group was comparatively less popular and had fewer friends, findings that are consistent with the literature on loneliness and isolation.

Emotional well-being has typically been measured using depression scales in studies on suicidal ideation among adolescents (Boergers et al., 1998; De Man, 1999; Fisher, 1999). Occasionally, anger and aggression have been explored as factors (Boergers et al., 1998; Stein et al., 1998). Yet, in the present study, how happy the adolescent feels accounted for 46% of the variance, suggesting that extreme depression is not necessary for suicidal ideation. Even moderate unhappiness can predict suicidal ideation. In this study, unhappiness was a stronger predictor than depression (which did not enter the stepwise regression equation) and anger (which accounted for 5% of the variance in suicidal ideation).

The group differences regarding the use of cigarettes, marijuana, and cocaine were not surprising inasmuch as drug use has frequently been noted to correlate not only with depression in samples of adolescents, but also with their suicidal thoughts and suicide attempts (Fombonne, 1998; Metha et al., 1998). The fact that grade point average was significantly lower in the suicidal ideation group was also not surprising, because of the previously reported relationship between GPA, depression, and drug use.

The constellation of factors that distinguished adolescents who experienced suicidal ideation--unhappiness, low number of friends, anger, and use of marijuana--parallels those that have been highlighted in the literature (i.e., depression, isolation/loneliness, anger/aggression, and substance use). That four variables accounted for two thirds of the variance in suicidal ideation is noteworthy. Nonetheless, 34% of the variance remained unexplained, suggesting the need for further research. In the interim, the questions used to measure these four variables might be included in global screenings to identify adolescents at risk for suicidal ideation.

The authors would like to thank the students who participated in this study, and Christy Cullen, Angelica Escalona, and Michelle Kaplan for their assistance with data collection. This research was supported by an NIMH Research Scientist Award (MH00331) to Tiffany Field, and funding from Johnson and Johnson to the Touch Research Institutes.

Miguel Diego and Christopher E. Sanders, Touch Research Institutes.

Reprint requests to Tiffany Field, Touch Research Institutes, University of Miami School of Medicine, Department of Pediatrics (D-820), P.O. Box 016820, Miami, Florida 33101. Electronic mail may be sent to tfield@med.miami.edu.

REFERENCES

Blyth, D. A., & Foster-Clark, F. S. (1987). Gender differences in perceived intimacy with different members of adolescents' social networks. Sex Roles, 17, 689-719.

Boergers, J., Spirito, A., & Donaldson, D. (1998). Reasons for adolescent suicide attempts: Associations with psychological functioning. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1287-1293.

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Field, T., & Yando, R. (1991). Adolescents' Self-Perceptions Scales. Unpublished scales.

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Jacobs, D. G., Brewer, M., & Klein-Benheim, M. (1999). Suicide assessment: An overview and recommended protocol. In D. G. Jacobs et al. (Eds.), The Harvard Medical School guide to suicide assessment and intervention. San Francisco, CA: Jossey-Bass.

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Mazza, J. J., & Reynolds, W. M. (1998). A longitudinal investigation of depression, hopelessness, social support, and major and minor life events and their relation to suicidal ideation in adolescents. Suicide and Life Threatening Behavior, 28, 358-374.

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Table 1
Mean Scores (and Standard Deviations)
for Suicidal Ideation Groups
Variable No Suicidal Suicidal t p
 Ideation Ideation
Relationship with Mother 28.8 (5.7) 22.2 (9.4) 3.59 .001
Intimacy with Parents 15.8 (2.8) 13.3 (4.7) 2.79 .01
Closeness to Siblings 3.6 (0.8) 2.9 (1.3) 2.91 .005
Maternal Depression [*] 1.4 (0.6) 2.1 (1.2) -3.61 .001
Peer Relations 30.8 (6.8) 27.0 (11.5) 1.72 .05
Popularity 3.2 (0.7) 2.2 (1.1) 4.27 .000
Number of Friends 4.5 (0.8) 3.4 (1.6) 4.28 .000
Well-being [*] 1.6 (0.6) 2.5 (1.1) -5.02 .001
Happiness [*] 1.4 (0.6) 2.5 (1.1) -5.31 .000
Anger 1.3 (0.4) 0.4 (0.5) -3.25 .005
Depression (CES-D) [*] 21.7 (11.0) 34.1 (10.0) -3.87 .000
Cigarettes [*] 2.0 (1.2) 3.1 (1.2) -3.18 .005
Marijuana [*] 2.2 (1.1) 3.2 (1.0) -3.25 .005
Cocaine [*] 1.2 (0.6) 2.2 (1.3) -4.45 .000
GPA 3.2 (0.7) 2.5 (1.4) 3.06 .005
(*)Lower score is optimal.
Table 2
Stepwise Regression for Suicidal Ideation
Variable R R-Square
Happiness .68 .46
Number of Friends .75 .57
Anger .79 .62
Marijuana Use .81 .66