Assessing the Relationship Between School Failure and Suicidal Behavior in Adolescents and Young Adults: A Systematic Review and Meta-analysis of Longitudinal Studies

Factors Associated with Suicidal Behavior in Adolescents: An Umbrella Review Using the Socio-Ecological Model

Adolescent suicide is a critical social issue with profound and lasting individual and collective consequences. This umbrella review examines factors associated with adolescent suicidal behavior through the socioecological framework of prevention and seeks to identify gaps in the existing literature. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and included a comprehensive search of the of the Web of Science, Scopus, and Cochrane databases in both English and Spanish, covering the period from 2018 to 2024, using terms related to adolescence and suicidal behavior. Out of 6,138 articles identified, 37 met the quality criteria and were selected for analysis. The studies highlighted individual risk factors such as age, gender, belonging to ethnic or gender minorities, emotional disorders, self-destructive behavior, emotional regulation, and experience of physical or emotional pain. Interpersonal factors such as parental relationships, sexual abuse, social isolation, peer pressure, and loneliness were also found. However, the review revealed a worrying lack of studies on societal and community factors and a paucity of research focusing on protective factors. The study highlights the need to include factors related to the physical and social environments that influence health and behavior in future research, as well as to enhance the resources and strengths of adolescents.

Prevalence and correlates of nonsuicidal self-injury among youths in Singapore: findings from the National Youth Mental Health Study

BACKGROUND

Nonsuicidal self-injury (NSSI) is a common phenomenon; a recent meta-analysis of studies conducted among non-clinical adolescents reported a global lifetime prevalence rate of 22.0%. NSSI results in significant impairment and is associated with negative outcomes later in young adulthood. There is, however, a dearth of research on the occurrence of NSSI in Singapore's youth population. Past studies examining NSSI behaviours among youths in Singapore were conducted using clinical samples, which tend to report a higher prevalence compared to community samples. The present study aims to establish the prevalence of NSSI and examine its associated sociodemographic and psychosocial correlates in the general youth population.

METHODS

This study included 2600 youths aged 15-35 years who participated in the National Youth Mental Health Study, a nationwide cross-sectional survey of the mental health status of youths in Singapore. The Deliberate Self-Harm Inventory and Depression Anxiety Stress Scales Short Form were used to assess NSSI behaviours and mental health symptoms. Data on coping strategies, perceived social support and resilience were also collected.

RESULTS

The lifetime prevalence of NSSI among youths in Singapore was 25.0%, and the 12-month prevalence was found to be 6.8%. The median age of onset for lifetime NSSI was 14 years. Significantly higher odds of lifetime NSSI were observed among youths aged 15-29 years, females, and youths with lower educational attainment. Youths with severe and extremely severe symptoms of depression and anxiety and those with greater use of avoidance coping strategy were associated with higher odds of lifetime NSSI. Higher resilience scores were associated with lower odds of lifetime NSSI.

CONCLUSION

1 in 4 youths in Singapore had engaged in self-injurious behaviour at least once in their lifetime. Screening and early intervention programs could be targeted at the more vulnerable youth groups such as those in early- and mid- adolescence. Potential areas for future research and interventions could include resilience building and educating youths on adaptive coping strategies. The limitations of the cross-sectional study design and the use of self-reported data should be considered when interpreting the study findings.

A longitudinal study of adolescent pathways differentiating suicide ideation and attempt in early adulthood

OBJECTIVE

Suicide ideation and attempt are leading risk factors for mortality in young adults. However, the adolescent risk factors distinguishing suicide ideation from attempt in young adults remain unclear. The present study aimed to examine the extent to which within-person stability and change in depressive symptoms, school difficulties, and peer victimization from ages 12 to 17 were differentially associated with later suicide ideation and attempt from ages 20 to 23.

METHOD

The study included 1647 participants from the Quebec Longitudinal Study of Child Development (QLSCD; 52% female). Participants reported on their depressive symptoms, school difficulties, and peer victimization at ages 12, 13, 15, and 17, and on suicide ideation and attempt at ages 20 and 23. Data were collected in the Province of Quebec, Canada, between 2010 and 2021.

RESULTS

Results indicated that 11% (N = 121) and 8% (N = 86) reported suicide ideation and attempt, respectively, between ages 20 and 23. A random-intercept cross-lagged panel model showed that within-person increases in depressive symptoms during adolescence were related to both suicide ideation and attempt, whereas within-person increases in school difficulties and peer victimization were for the most part related to suicide attempt only. Within-person stability in depressive symptoms from ages 12 to 17 years were also related to suicide attempt, and not ideation. However, this association was only marginally significant.

CONCLUSION

Findings suggest that experiencing unusual rises in school difficulties and peer victimization during adolescence, as well as depressive symptoms persisting over time, may distinguish young adults who think about suicide from those who attempt suicide.

Rural-urban and age differences in association between depression and suicidal attempt: a large retrospective clinical sample study in China

OBJECTIVES

To assess the association between depression and suicide attempt (SA) by age and region.

DESIGN

Cross-sectional study.

SETTING

First Affiliated Hospital of Wannan Medical College from January 2021 to January 2022.

PARTICIPANTS

Hospitalised patients.

PRIMARY OUTCOME MEASURES

SA was the primary outcome and data on SA was obtained from the electronic medical records of hospitalised patients.

METHODS AND ANALYSIS

In this study, data on inpatients of the First Affiliated Hospital of Wannan Medical College from January 2021 to January 2022 were extracted from the medical record system using the convenience sampling method. According to the exclusion criteria, 7593 eligible research subjects were obtained. Logistic regression analysis was used to assess the association between depression and SA, combining age and region. Subgroup analyses were carried out to assess the relationship between age, region and SA in depressed patients, after excluding non-depressed patients, and to inspect the interaction of age and region. Finally, further comparisons of the disparities in suicide patterns among different age groups and regional groups were made.

RESULTS

Among 7593 patients (3630 males), 655 (8.6%) patients with SA were observed. We found that depression was significantly associated with SA by age and region (all p<0.05). Specifically, depressed juveniles and adults had a higher risk of SA compared with non-depressed adults, and ORs (95% CIs) were 2.62 (1.59 to 4.30) and 1.67 (1.30 to 2.13), respectively. Furthermore, rural individuals with depression, urban individuals without depression and urban individuals with depression had a higher risk of SA compared with rural participants without depression, and ORs (95% CIs) were 1.60 (1.22 to 2.12), 1.29 (1.04 to 1.61) and 2.53 (1.83 to 3.49), respectively. In subgroup analyses, we further found that depression was strongly associated with SA in juveniles (OR 2.84, 95% CI 1.19 to 6.76, p=0.018) and urban patients (OR 1.67, 95% CI 1.15 to 2.40, p=0.006). Notably, the predominant methods of suicide among individuals with depression were the utilisation of sleeping pills or antidepressants.

CONCLUSION

Our study found individuals with depression are at higher risk of SA, especially juveniles and urban individuals. Effective integration of mental health and urban-rural services could mitigate the risk of suicide and contribute to better outcomes.

A Study on Deliberate Self-Harm by Poisoning and Associated Risk Factors at Batticaloa Teaching Hospital

BACKGROUND

Deliberate self-harm (DSH) by poisoning is a significant public health concern worldwide. This study aimed to analyze the demographic, socioeconomic, and psychological factors contributing to self-harm by poisoning in patients admitted to a tertiary care hospital in Sri Lanka.

METHODS

A cross-sectional study was conducted on 101 patients admitted to the hospital for poisoning-related self-harm. Data was collected through a structured questionnaire. Variables such as age, gender, educational background, employment status, income levels, substance abuse history, type of poisons used, sources of knowledge about self-harm methods, immediate stressors, and other few possible factors were analyzed.

RESULTS

The majority of patients, 55 (54.5%), were between the ages of 18 and 29. Fifty-five women (54.5%) slightly outnumbered 46 men (45.5%). More than half of the included patients had an educational background of up to ordinary level exam, while 58 were unemployed (57.4%), including dependents. Lower income levels were associated with higher rates of self-harm. Substance abuse, particularly alcohol, was prevalent in 34 (33.7%) of cases. The most commonly used poison was yellow oleander, reported in 38 (37.6%) of cases. The study also found that a majority, 53 (52.5%), learned about self-harm methods through community engagement. Immediate stressors, including arguments with parents, 29 (28.7%), and conflicts with spouses, 19 (18.8%), were significant triggers. Most patients, 76 (75.2%), were admitted to the hospital within six hours of poisoning. Half of the patients, 50 (50%), reported that immediate stressors directly related to the COVID-19 pandemic significantly influenced their decision to self-harm. Regarding patient outcomes, the study found that nearly all patients, 100 (99%), were successfully discharged from the hospital after treatment.

CONCLUSION

This study provides valuable insights into the factors contributing to DSH by poisoning in a Sri Lankan context. Targeted interventions addressing the identified risk factors, along with broader public health strategies, are essential to reduce the incidence of self-harm.

Association Between School-Related Google Trends Search Volume and Suicides Among Children and Adolescents in Japan During 2016-2020: Retrospective Observational Study With a Time-Series Analysis

BACKGROUND

Suicide is the leading cause of death among children and adolescents in Japan. Internet search volume may be useful in detecting suicide risk. However, few studies have shown an association between suicides attempted by children and adolescents and their internet search volume.

OBJECTIVE

This study aimed to examine the relationship between the number of suicides and the volume of school-related internet searches to identify the search terms that could serve as the leading indicators of suicide prevention among children and adolescents.

METHODS

We used data on weekly suicides attempted by elementary, middle, and high school students in Japan from 2016 to 2020, provided by the National Police Agency. Internet search volume was weekly data for 20 school-related terms obtained from Google Trends. Granger causality and cross-correlation analysis were performed to estimate the temporal back-and-forth and lag between suicide deaths and search volume for the related terms.

RESULTS

The search queries "I do not want to go to school" and "study" showed Granger causality with suicide incidences. The cross-correlation analysis showed significant positive correlations in the range of -2 to 2 for "I do not want to go to school" (highest value at time lag 0, r=0.28), and -1 to 2 for "study" (highest value at time lag -1, r=0.18), indicating that the search volume increased as the number of suicides increased. Furthermore, during the COVID-19 pandemic period (January-December 2020), the search trend for "I do not want to go to school," unlike "study," was highly associated with suicide frequency.

CONCLUSIONS

Monitoring the volume of internet searches for "I do not want to go to school" could be useful for the early detection of suicide risk among children and adolescents and for optimizing web-based helpline displays.

Negative affect influences suicide-specific attentional biases

Background

Studies using tasks that measure suicide-specific attentional biases have not specified which attentional processes are related to risk for suicidal thoughts and behaviors. This study distinguished suicide-specific engagement and disengagement biases from other forms of cognitive processing and investigated under which affective conditions suicide-specific biases emerged.

Method

An ethnoracially and socioeconomically diverse sample of 153 young adults (87 % female; 52 % Non-Hispanic White), ages 18-34, with moderate-to-high symptoms of anxiety, depression, or recent suicide ideation were randomly assigned to experience positive, negative, or neutral affect, completed cognitive tasks of attention, construct accessibility, and threat bias, and self-report measures.

Results

Individuals with recent ideation displayed facilitated disengagement from suicide-specific stimuli irrespective of affective state. Those with distal ideation showed slower disengagement from suicide-specific stimuli in the sad condition only.

Conclusions

Individuals with recent suicide ideation display automatic processing of suicide-related information, perhaps due to recent rehearsal of suicide-related content. In contrast, individuals with distal ideation experiencing negative affect appear to have difficulty disengaging attention from suicide-related content. Limits to generalizability of the findings include a predominantly female sample, although the sample's racial, ethnic, and socioeconomic diversity increase generality of the research.

Exploring risk factors and their differences on suicidal ideation and suicide attempts among depressed adolescents based on decision tree model

BACKGROUND

Suicide has been recognized as a major global public health issue. Depressed adolescents are more prone to experiencing it. We explore risk factors and their differences on suicidal ideation and suicide attempts to further enhance our understanding of suicidal behavior.

METHODS

2343 depressed adolescents aged 12-18 from 9 provinces/cities in China participated in this cross-sectional study. We utilized decision tree model, incorporating 32 factors encompassing participants' suicidal behavior. The feature importance of each factor was measured using Gini coefficients.

RESULTS

The decision tree model demonstrated a good fit with high accuracy (SI = 0.86, SA = 0.85 and F-Score (SI = 0.85, SA = 0.83). The predictive importance of each factor varied between groups with suicidal ideation and with suicide attempts. The most significant risk factor in both groups was depression (SI = 16.7 %, SA = 19.8 %). However, factors such as academic stress (SI = 7.2 %, SA = 1.6 %), hopelessness (SI = 9.1 %, SA = 5.0 %), and age (SI = 7.1 %, SA = 3.2 %) were more closely associated with suicidal ideation than suicide attempts. Factors related to the schooling status (SI = 3.5 %, SA = 10.1 %), total years of education (SI = 2.6 %, SA = 8.6 %), and loneliness (SI = 2.3 %, SA = 7.4 %) were relatively more important in the suicide attempt stage compared to suicidal ideation.

LIMITATIONS

The cross-sectional design limited the ability to capture changes in suicidal behavior among depressed adolescents over time. Possible bias may exist in the measurement of suicidal ideation.

CONCLUSION

The relative importance of each risk factor for suicidal ideation and attempted suicide varies. These findings provide further empirical evidence for understanding suicide behavior. Targeted treatment measures should be taken for different stages of suicide in clinical interventions.

Risk and protective factors for self-harm in adolescents and young adults: An umbrella review of systematic reviews

We conducted an umbrella review to synthesise the evidence from systematic reviews and meta-analyses that examined the risk and protective factors for self-harm in young people. We searched six different databases and used the AMSTAR-2 checklist for quality assessment. The importance of each risk and protective factor was determined based on (1) the number of times it was identified by general reviews examining any risk or protective factor, and (2) the effect sizes from meta-analyses. There were 61 systematic reviews included in this review. The most frequently identified risk factors for self-harm in young people included childhood abuse, depression/anxiety, bullying, trauma, psychiatric illnesses, substance use/abuse, parental divorce, poor family relationships, lack of friends, and exposure to self-harm behaviour in others. The risk factors with the strongest evidence for an association with self-harm were behavioural disorders, personality disorders and depression or anxiety. There was a dearth of systematic reviews examining protective factors but good family/friend relationships were most frequently identified. There was also evidence to show that non-suicidal and suicidal self-harm shared many of the same risk factors. Clinicians and other professionals who work with young people should be particularly cognisant of the psychiatric and adverse life event risk factors as well as the substance use, education-related and individual-level (e.g. being LGB) risk factors for self-harm. Knowledge of risk factors for self-harm can potentially be used to inform the design and implementation of prevention measures and further research is needed on the protective factors for self-harm.

Differentiating the associations between alcohol use, cigarette smoking, and conditional suicidal behaviors among adolescents

BACKGROUND

Both alcohol use and cigarette smoking have been identified as risk factors for suicidal behaviors. However, suicide is a process from ideation to action, and some evidence have implied us that alcohol use and cigarette smoking may play different roles in the different process of suicidal behaviors.

METHODS

Data was derived from the 2019 Youth Risk Behavior Survey (YRBS), and a total of 12, 487 valid samples were analyzed in the study. To distinguish the different situation of suicidal behaviors, participants were divided into general people without any suicidal behavior (GNS), suicidal ideators without plan or attempt (SINPA), suicide planners without attempt (SPNA), and suicide attempters (SA).1 RESULTS: The prevalence of suicidal ideation, plan, and attempt were 19.4 %, 15.9 %, and 7.7 %, respectively. Comparing to GNS, alcohol use and cigarette smoking were associated with SINPA (OR = 1.27, P < 0.05; OR = 1.47, P < 0.001), SPNA (OR = 1.29, P < 0.01; OR = 1.26, P < 0.01), and SA (OR = 1.31, P < 0.01; OR = 2.11, P < 0.001). However, alcohol use was not associated with SA comparing to SINPA (OR = 1.05, P > 0.05) and SPNA (OR = 1.03, P > 0.05), while cigarette smoking was associated with SA (OR = 1.40, P < 0.01; OR = 1.74, P < 0.001).

LIMITATIONS

Firstly, using the secondary data was possibly limited. Next, this was a cross-sectional study, the casual relationship was unsure. Lastly, the amount of alcohol consumption and cigarette smoking status were not considered.

CONCLUSION

Both alcohol use and cigarette smoking are risk factors for any suicidal behaviors. However, controlling alcohol use may be a limited method to prevent the further suicidal behaviors for ideators and planners. Managing cigarette smoking should be considered.

Association of Depressive Symptoms in Late Adolescence and School Dropout

The present study investigated the association between symptoms of depression in late adolescence and completion of upper secondary school, taking symptoms of ADHD and conduct disorder, and parental education into account. The study is based on the youth@hordaland-survey, conducted in Western Norway in 2012. A total of 9157 adolescents (aged 16–19 years, 53% girls) consented to participation and registry linkage and comprised the sample of the present study. Symptoms of depression, ADHD, and conduct disorder were based on adolescent self-report. Information on parental education, grade point average (GPA), and upper secondary school completion was retrieved from the National Education Database. In the sample, 14.8% had not completed upper secondary education within 5 years. Symptoms of depression were associated with higher odds of failure to graduate within 5 years (adjusted odds ratio (AOR) = 1.50). The association was attenuated but remained significant when adjusting for symptoms of ADHD, conduct disorder, and parental education. Adolescents reporting high levels of both depression and conduct disorder had the highest odds of dropout (AOR = 4.15). GPA partially mediated the association between symptoms of depression and dropout. The results show a consistent, but small association between symptoms of depression in late adolescence and failure to complete upper secondary education within five years. Given the high rate of depressive symptoms in the adolescent population, it is important to identify protective factors that promote school functioning and graduation for adolescents experiencing such symptoms.

How Worries about Interpersonal Relationships, Academic Performance, Family Support, and Classmate Social Capital Influence Suicidal Ideation among Adolescents in Japan

Suicide is an important public health issue for adolescents. To investigate the risk and protective factors for adolescent suicide, a cross-sectional questionnaire-based survey was conducted at a junior high school (n = 379) in Japan in 2018. After obtaining survey data, we conducted univariate and logistic regression analyses to test for associations between suicidal ideation and several factors, including worries (i.e., about school life, interpersonal relationships at school, family life, interpersonal relationships at home, and academic performance), perceived support from school staff and family members, and social capital. In this context, the existence of trustful relationships between classmates was used as indicators of social capital. The results showed that the prevalence of suicidal ideation was 10.5%. The risk of suicidal ideation was increased by worries about 1) interpersonal relationships at school, 2) interpersonal relationships at home, and 3) academic performance, but was decreased by social support from family members and trusting relationships. Further, the rate of suicidal ideation was higher among students who expressed all these three worries when compared to those who expressed two or fewer worries. In addition, looking at students who expressed all these three worries simultaneously, the rate of suicidal ideation was higher among those with lower levels of support from family members and fewer trustful relationships. Our results suggest that the prevention of adolescent suicide should include strategies for reducing worries about interpersonal relationships at school/home and academic performance while finding ways to enhance family support and classmate social capital.

Effectiveness of a Continuity-of-Care Model to Reduce Youth Suicidality

Background: Suicidal ideation and recent suicide attempts greatly increase the risk of suicide among youth. Many youth experiencing suicidality are not adequately connected to in-person treatment. Aims: This study aimed to determine the efficacy of a continuity-of-care approach in reducing suicide attempts, ideation, and related hospital and emergency department (ED) visits among youth at high risk for suicide. Method: Data on suicidal ideation, attempts, and related hospital and ED visits were collected over a 6-month period for youth under age 25 (n = 376). One-way repeated measures ANOVA and Cochran's Q tests assessed change from intake at the 3- and 6-month follow-up. Results: Youth had significantly fewer suicide attempts and related hospital and ED visits at both 3- and 6-month timepoints. Suicidal ideation decreased to 52% from intake to 6-month follow-up. Limitations: This study lacked a comparison population to examine continuity-of-care versus treatment-as-usual. Furthermore, the study did not extend beyond 6 months, limiting the ability to assess the intervention's long-term effectiveness. Conclusion: This youth-focused continuity-of-care model reduced suicidal ideation and related behaviors. Further studies should utilize control groups to confirm the validity of these results.

Suicidality, function and associated negative life events in an adolescent psychiatric population at 3-year follow-up

BACKGROUND

We aimed to examine psychosocial function, suicidality and school dropout in a clinical psychiatric population over a 3-year period from adolescence to young adulthood and explore associations with negative life events.

METHODS

This study is part of the Health Survey in Department of Children and Youth, St. Olavs hospital, Norway. In the first study visit (T1), 717 (43.5% of eligible) participated, aged 13-18 years (2009-2011), and 3 years later (T2), 570 answered a questionnaire (school functioning and negative life events), and 549 completed Kiddie SADS as telephone interview assessing DSM-IV diagnoses, psychosocial functioning and suicidality.

RESULTS

Suicidal ideation was more frequent among girls (17.9%) than among boys (5.4%) (risk difference; RD = 12.5%, CI (7.2 to 17.7), p < 0.001), as was suicidal behavior (25.0% vs. 9.5%, RD = 15.5%, CI (9.2 to 21.4), p < 0.001). Girls had lower psychosocial functioning than boys (Children's Global Assessment Scale; Mean score 68.2 vs. 75.2, Mean difference = - 7.0, CI (- 9.4 to - 4.7), p < 0.001), and more school dropout (22.5% vs. 13.2%, RD = 9.3%, CI (2.8 to 15.5), p = 0.006). For those with a psychiatric disorder, 24.8% of girls had suicidal ideation and 30.0% suicidal behavior, which was larger than for boys (RD = 18.0%, CI (10.8 to 24.7), p < 0.001, and RD = 18.3%, CI (10.2 to 25.8), p < 0.001, respectively). Exposure to negative life events was frequent for both genders, but more girls had experienced sexually uncomfortable or abusive situations, the last 3 years (23.5% vs. 2.9%, RD = 20.6%, CI (15.4 to 25.7), p < 0.001), and ever (44.4% vs. 7.9%, RD = 36.5%, CI (29.9 to 42.7), p < 0.001). Suicidal behavior was associated with having been threatened, physically harassed or violently hurt (RD = 16.7%, CI (9.5 to 23.9), p < 0.001), and for girls been put into sexually uncomfortable or abusive situations (RD = 20.1%, CI (10.4 to 29.9), p < 0.001) and seen others violently hurt (RD = 14.6%, CI (3.4 to 25.8), p = 0.011).

CONCLUSIONS

The high frequency of suicidality and school dropout confirms the severity of adolescent psychiatric disorders, especially among girls. Specific life events were associated risk factors and should be target points for prevention and intervention.