Individual- and area-level influence on suicide risk: a multilevel longitudinal study of Swedish schoolchildren

Preschool-level socio-economic deprivation in relation to emotional and behavioural problems among preschool children in Sweden

AIMS

The aim of this study was to explore the association between preschool-level socio-economic deprivation and emotional and behavioural problems among preschool children in Sweden using a multilevel approach.

METHODS

In this cross-sectional study, we used data on 2267 children whose parents and preschool teachers had responded to items measuring individual-level socio-economic deprivation and the Strengths and Difficulties Questionnaire (SDQ) for assessment of emotional and behavioural problems. Further, the Socioeconomic Structure Compensation Index (SSCI), collected from Uppsala municipality, was used to assess preschool-level socio-economic deprivation. Unadjusted and adjusted multilevel logistic regression models were used to explore the relations between preschool-level socio-economic deprivation and emotional and behavioural problems.

RESULTS

In unadjusted models, children who attended preschools classified as highly deprived had elevated odds for emotional symptoms (odds ratio (OR) 1.71) as rated by parents. However, this association did not remain significant after adjusting for individual-level socio-economic deprivation factors. In both unadjusted and adjusted models, children who attended preschools classified as moderately deprived had elevated odds for peer-relationship problems as rated by parents (OR 1.63; adjusted OR 1.48). There were no significant associations between preschool deprivation and emotional and behavioural problems as rated by preschool teachers.

CONCLUSIONS

Swedish preschools may have a compensatory capacity in addressing children's emotional and behavioural problems, whereas preschool-level deprivation remained significantly associated with peer-relationship problems after controlling for individual-level socio-economic deprivation factors. This implies that peer-relationship problems in deprived preschools need to be addressed in a broader community context.

The impact of area-level socioeconomic status in childhood on mental health in adolescence and adulthood: A prospective birth cohort study in Aotearoa New Zealand

Mental health conditions pose a significant public health challenge, and low area-level socioeconomic status (SES) is a potentially important upstream determinant. Childhood exposure might have influences on later-life mental health. This study, utilises data from the Christchurch Health and Development Study birth cohort, examining the impact of area-level SES trajectories in childhood (from birth to age 16) on mental health at age 16 and from age 18-40 years. Findings revealed some associations between distinct SES trajectories and mental health. The study underscores the importance of using a spatial lifecourse epidemiology framework to understand long-term environmental impacts on later-life health.

The developmental origins of suicide mortality: a systematic review of longitudinal studies

Suicide prevention efforts generally target acute precipitants of suicide, though accumulating evidence suggests that vulnerability to suicide is partly established early in life before acute precipitants can be identified. The aim of this systematic review was to synthesize evidence on early life vulnerability to suicide beginning in the prenatal period and extending through age 12. We searched PubMed, Embase, PsycNet, Web of Science, Scopus, Social Services Abstracts, and Sociological Abstracts for prospective studies published through January 2021 that investigated early life risk factors for suicide mortality. The search yielded 13,237 studies; 54 of these studies met our inclusion criteria. Evidence consistently supported the link between sociodemographic (e.g., young maternal age at birth, low parental education, and higher birth order), obstetric (e.g., low birth weight), parental (e.g., exposure to parental death by external causes), and child developmental factors (e.g., exposure to emotional adversity) and higher risk of suicide death. Among studies that also examined suicide attempt, there was a similar profile of risk factors. We discuss a range of potential pathways implicated in these associations and suggest that additional research be conducted to better understand how early life factors could interact with acute precipitants and increase vulnerability to suicide.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

The complexities of suicide: a multilevel survival analysis examining individual, familial and neighbourhood determinants of suicide risk using Danish register-based data

BACKGROUND

Suicide risk is complex and nuanced, and how place impacts suicide risk when considered alongside detailed individual risk factors remains uncertain. We aimed to examine suicide risk in Denmark with both individual and neighbourhood level risk factors.

METHODS

We used Danish register-based data to identify individuals born in Denmark from 1972, with full parental information and psychiatric diagnosis history. We fitted a two-level survival model to estimate individual and neighbourhood determinants on suicide risk.

RESULTS

We identified 1723 cases of suicide in Denmark during the follow-up period from 1982 to 2015. Suicide risk was explained mainly by individual determinants. Parental comorbidities, particularly maternal schizophrenia [incidence rate ratio (IRR): 2.29, 95% CI 1.56-3.16] and paternal death (2.29, 95% CI 1.31-3.72) partly explained suicide risk when adjusted for all other determinants. The general contextual effect of suicide risk across neighbourhoods showed a median incidence rate ratio (MRR) of 1.13 (1.01-1.28), which was further reduced with full adjustment. Suicide risk increased in neighbourhoods with a higher proportion of manual workers (IRR: 1.08; 1.03-1.14), and decreased with a higher population density (IRR: 0.89; 0.83-0.96).

CONCLUSION

Suicide risk varies mainly between individuals, with parental comorbidities having the largest effect on suicide risk. Suicide risk was less impacted by neighbourhood, though, albeit to a lesser extent than individual determinants, some characteristics were associated with suicide risk. Suicide prevention policies might consider targeting interventions towards individuals more vulnerable due to particular parental comorbidities, whilst taking into account that some neighbourhood characteristics might exacerbate this risk further.

Objective and subjective neighbourhood characteristics and suicidality: a multilevel analysis

BACKGROUND

Characteristics of the neighbourhood environment, including population density, social fragmentation, and trust, have been linked to mental health outcomes. Using a longitudinal population-based cohort, we explored the relationship between objective and subjective neighbourhood characteristics and the odds of suicidal thoughts and attempts.

METHODS

We conducted a longitudinal study of 20764 participants living in Stockholm County who participated in the Stockholm Public Health Survey. We used multilevel modelling to examine if suicidal thoughts and attempts were associated with neighbourhood characteristics, independent of individual associations. We included objective and subjective measures to explore if there was a different relationship between these measures of the neighbourhood environment and suicidality.

RESULTS

Associations between neighbourhood factors and suicidality were predominantly explained by individual characteristics, with the exception of neighbourhood-level deprivation and average residential trust. Each unit increase of deprivation was linked to increased odds of suicidal thoughts [Odds ratio (OR) 1.04, 95% confidence interval (CI) 1.00-1.07] and attempts (OR 1.11, 95% CI 1.06-1.17). Decreasing residential trust was associated with increased odds of suicide attempts (OR 1.09, 95% CI 1.02-1.17). There was no evidence that neighbourhood-level fragmentation or average trust in public and political institutions had an independent effect on suicidality once individual and sociodemographic factors were accounted for.

CONCLUSIONS

This study showed that much of the neighbourhood-level variation in suicidal thoughts and attempts could be explained by compositional factors, including sociodemographic clustering within neighbourhoods. The independent effect of neighbourhood-level deprivation and average residential trust provide evidence that the neighbourhood context may exert an independent effect on suicidality beyond the impact of individual characteristics.

Neighborhood social context and suicide mortality: A multilevel register-based 5-year follow-up study of 2.7 million individuals

Previous studies have linked neighborhood social characteristics to suicide mortality. However, the effects of the operational definition of neighborhoods and the general importance of neighborhood context on suicide mortality have received little attention, with most studies using various administrative areas as neighborhood delineations. In this study, neighborhoods were delineated by micro-areas generated with an automated redistricting algorithm and divided by physical barriers, such as large roads. The geographic data were linked to register data on the Danish adult population in the age range of 20-59 years in December 2013 (N = 2,672,799 individuals nested into 7943 neighborhoods). This cohort was followed for five years to evaluate the association between suicide mortality and neighborhood socioeconomic deprivation, social fragmentation, and population density. We used the median hazard ratio (MHR) to quantify the general contextual effect (GCE) of neighborhoods on suicide mortality and hazard ratios to quantify the specific contextual effects (SCEs) using multilevel survival models stratified by age group. The results showed a larger GCE and larger SCEs of neighborhoods on suicide mortality for individuals aged 20-39 years compared with those aged 40-59 years. After controlling for individual characteristics, higher suicide mortality was observed for individuals living in the least densely populated neighborhoods and the most socially fragmented neighborhoods for both age groups. We found cross-level interactions between neighborhood population density and gender and ethnicity for those aged 40-59 years, as well as between neighborhood social fragmentation and ethnicity for those aged 20-39 years. The results indicate that beyond individual characteristics, the neighborhood social context may affect the risk of suicide, especially for people aged 20-39 years.

Prevalence of Suicide in Immigrants/Refugees: A Systematic Review and Meta-Analysis

OBJECTIVE

In recent years, there has been an increase in immigrant populations worldwide. This study aims to present the global prevalence of suicide between immigrants and refugees as well as to report the prevalence of suicide ideation, suicide mortality, suicide attempts, and plan of suicide.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA's) rules were used as a guide in the current research path. PubMed and EMBASE were targeted for the study until December 2019. After collecting the data, the number of events and sample size extracted for each study and also pooled odds ratio and confidence interval (CI) were used to investigate the suicide ratio among immigrants and refugees compared to the native population.

RESULTS

Fifty-one studies were included in the meta-analysis to investigate suicide prevalence or suicide odds ratio. The prevalence of suicidal ideation was 16% (CI: 0.12-0.20, I2 = 99.4%), for attempted suicide was 6% (CI: 0.05-0.08, I2 = 98.0%), and for suicide plan prevalence was 4% (CI: 0.00-0.08, I2 = 96.8%). The prevalence of suicidal ideation was 10% (CI: 0.04-0.17, I2 = 0.0%) in men and 17% (CI: 0.10-0.24, I2 = 96.8%) in women. The prevalence of attempted suicide was 1% (CI: 0.01-0.02, I2 = 0.0%) in men and 7% (CI: 0.03-0.10, I2 = 94.4%) in women. The odds ratio of suicide mortality among immigrants was 0.91 (CI: 0.90-0.93, p < 0.001; I2 = 97.6%) and for attempted suicide was 1.15 (CI: 1.10-1.20, p < 0.001; I2 = 92.0%). Begg's test (p = 0.933) (Egger test; p = 0.936) rejected publication bias.

CONCLUSION

Given the high prevalence of suicide, especially suicide ideation and suicide attempts in immigrants, increased attention needs to be paid to the mental health of this population.

The Role of Schools in Early Adolescents' Mental Health: Findings From the MYRIAD Study

OBJECTIVE

Recent studies suggest mental health in youths is deteriorating. The current policy in the United Kingdom emphasizes the role of schools for mental health promotion and prevention, but little data exist on what aspects of schools influence mental health in pupils. This study explored school-level influences on the mental health of young people in a large school-based sample from the United Kingdom.

METHOD

Baseline data from a large cluster randomized controlled trial collected between 2016 and 2018 from mainstream secondary schools selected to be representative in relation to their quality rating, size, deprivation, mixed or single-sex pupil population, and country were analyzed. Participants were pupils in their first or second year of secondary school. The study assessed whether school-level factors were associated with pupil mental health.

RESULTS

The study included 26,885 pupils (response rate = 90%; age range, 11‒14 years; 55% female) attending 85 schools in the United Kingdom. Schools accounted for 2.4% (95% CI: 2.0%‒2.8%; p < .0001) of the variation in psychopathology, 1.6% (95% CI: 1.2%‒2.1%; p < .0001) of depression, and 1.4% (95% CI: 1.0%‒1.7%; p < .0001) of well-being. Schools in urban locations, with a higher percentage of free school meals and of White British, were associated with poorer pupil mental health. A more positive school climate was associated with better mental health.

CONCLUSION

School-level variables, primarily related to contextual factors, characteristics of pupil population, and school climate, explain a small but significant amount of variability in mental health of young people. This information might be used to identify schools that are in need of more resources to support mental health of young people.

CLINICAL TRIAL REGISTRATION INFORMATION

MYRIAD: My Resilience in Adolescence, a Study Examining the Effectiveness and Cost-Effectiveness of a Mindfulness Training Programme in Schools Compared With Normal School Provision; https://www.isrctn.com/; 86619085.

The impact of life course exposures to neighbourhood deprivation on health and well-being: a review of the long-term neighbourhood effects literature

Background

In this review article, we detail a small but growing literature in the field of health geography that uses longitudinal data to determine a life course component to the neighbourhood effects thesis. For too long, there has been reliance on cross-sectional data to test the hypothesis that where you live has an effect on your health and well-being over and above your individual circumstances.

Methods

We identified 53 articles that demonstrate how neighbourhood deprivation measured at least 15 years prior affects health and well-being later in life using the databases Scopus and Web of Science.

Results

We find a bias towards US studies, the most common being the Panel Study of Income Dynamics. Definition of neighbourhood and operationalization of neighbourhood deprivation across most of the included articles relied on data availability rather than a priori hypothesis.

Conclusions

To further progress neighbourhood effects research, we suggest that more data linkage to longitudinal datasets is required beyond the narrow list identified in this review. The limited literature published to date suggests an accumulation of exposure to neighbourhood deprivation over the life course is damaging to later life health, which indicates improving neighbourhoods as early in life as possible would have the greatest public health improvement.

Suicide risk among refugees compared with non-refugee migrants and the Swedish-born majority population

BACKGROUND

It has been hypothesised that refugees have an increased risk of suicide.

AIMS

To investigate whether risk of suicide is higher among refugees compared with non-refugee migrants from the same areas of origin and with the Swedish-born population, and to examine whether suicide rates among migrants converge to the Swedish-born population over time.

METHOD

A population-based cohort design using linked national registers to follow 1 457 898 people born between 1 January 1970 and 31 December 1984, classified by migrant status as refugees, non-refugee migrants or Swedish-born. Participants were followed from their 16th birthday or date of arrival in Sweden until death, emigration or 31 December 2015, whichever came first. Cox regression models estimated adjusted hazard ratios for suicide by migrant status, controlling for age, gender, region of origin and income.

RESULTS

There were no significant differences in suicide risk between refugee and non-refugee migrants (hazard ratio 1.28, 95% CI 0.93-1.76) and both groups had a lower risk of suicide than Swedish born. During their first 5 years in Sweden no migrants died by suicide; however, after 21-31 years their suicide risk was equivalent to the Swedish-born population (hazard ratio 0.94, 95% CI 0.79-1.22). After adjustment for income this risk was significantly lower for migrants than the Swedish-born population.

CONCLUSIONS

Being a refugee was not an additional risk factor for suicide. Our findings regarding temporal changes in suicide risk suggest that acculturation and socioeconomic deprivation may account for a convergence of suicide risk between migrants and the host population over time.

DECLARATION OF INTEREST

None.

Cross-level sociodemographic homogeneity alters individual risk for completed suicide

Recent unexpected increases in US suicides reinforce calls for fresh approaches to understanding suicide risk. Theorizing the complexity of suicide risk and harmonizing existing large data sources, we find two distinct patterns. Having more similar others in a geographical context dampens suicide risk for non–native-born, unemployed, and widowed individuals. However, social similarity heightens suicide risk in counties with a larger share of some race/ethnic and marital status groups. Knowing how social contexts alter individual suicide risk suggests innovative research directions, and provides paths to craft personalized and tailored strategies for anti-suicide programs, policies, and treatment.

Among deaths of despair, the individual and community correlates of US suicides have been consistently identified and are well known. However, the suicide rate has been stubbornly unyielding to reduction efforts, promoting calls for novel research directions. Linking levels of influence has been proposed in theory but blocked by data limitations in the United States. Guided by theories on the importance of connectedness and responding to unique data challenges of low base rates, geographical dispersion, and appropriate comparison groups, we attempt a harmonization of the National Violent Death Reporting System (NVDRS) and the American Community Survey (ACS) to match individual and county–level risks. We theorize cross-level sociodemographic homogeneity between individuals and communities, which we refer to as “social similarity” or “sameness,” focusing on whether having like-others in the community moderates individual suicide risks. While analyses from this new Multilevel Suicide Data for the United States (MSD-US) replicate several individual and contextual findings, considering sameness changes usual understandings of risk in two critical ways. First, high individual risk for suicide among those who are younger, not US born, widowed or married, unemployed, or have physical disabilities is cut substantially with greater sameness. Second, this moderating pattern flips for Native Americans, Alaska Natives, Asians, and Hispanics, as well as among native-born and unmarried individuals, where low individual suicide risk increases significantly with greater social similarity. Results mark the joint influence of social structure and culture, deliver unique insights on the complexity of connectedness in suicide, and offer considerations for policy and practice.

Education, immigration and rising mental health inequality in Sweden

Educational and income gradients in health are well established in the literature but there is need for a better understanding of how mental health inequalities change over time, and what drives the development. We aim to study how psychiatric diagnosis and its income-related inequality have changed over time in Sweden and to make a first attempt at disentangling the development by decomposing any changes in terms of changes in two important demographic characteristics: education and migration background. We use administrative patient data to study psychiatric inpatient diagnosis in the years 1994 and 2011. The study population comprises all individuals aged 31-64 years living in Sweden. Income-related inequalities are measured by the Concentration Index (CI). We decompose changes in the probability of receiving a diagnosis and changes in income-related inequality over time to understand the role of changing demographics. Our results show that over the study period the probability of receiving a psychiatric inpatient diagnosis increased by 12.6%, while the relative and absolute income-related inequalities in diagnosis increased by 48.2% and 66.7% respectively. In 2011, more than half of psychiatric inpatients were found among the poorest fifth of the population. The decomposition results suggest that changes in education and migration background have not played a substantial role in determining these increases. Education levels increased substantially over the study period which would be expected to protect against mental ill-health. Instead, we find that diagnoses have become more concentrated amongst the lowest educated individuals and the lowest income families, groups who appear to be increasingly disadvantaged. The growing proportion of individuals with foreign background in Sweden does, in fact, predict small increases in the probability of diagnosis, while the impact on diagnosis inequality varies depending on the definition of foreign background.

Suicide risk around the world: a meta-analysis of longitudinal studies

PURPOSE

Suicidal thoughts and behaviors (STBs) have been a persistent problem worldwide. Identifying risk factors for STBs across distinct areas of the world may help predict who or where requires the greatest attention. However, risk factors for STBs are infrequently explored cross-nationally. The present study examined whether psychopathology prospectively predicts STBs across different areas of the world, and whether certain country-level factors moderate the degree of risk conferred.

METHODS

We conducted a meta-analysis of 71 longitudinal studies from 30 different countries that featured psychopathology-related variables predicting STB outcomes. Meta-regression was used to evaluate whether the following country-level factors modified risk: geographic region, income level, and degree of mental health structural stigma.

RESULTS

Over 90% of studies had been conducted in North America and Europe. When assessed by country income level, it was found that only one longitudinal study on psychopathology and STB was conducted outside of a high-income country. Moreover, less than 10% of studies were conducted in high structural stigma contexts. Meta-regression findings revealed that the variation in risk effect sizes across studies was not explained by models including country-level factors.

CONCLUSIONS

Our findings show critical underrepresentation of low- and middle-income countries, which account for a large proportion of global suicide deaths. This reveals a need to broaden the scope of longitudinal research on STB risk, such that countries across more regions, income levels, and degrees of structural stigma are fully accounted for. Such lines of research will improve generalizability of findings, and more precisely inform prevention efforts worldwide.

Influence of Area-Level Characteristics on the Suicide Rate in Korean Adolescents

OBJECTIVE

We aimed to investigate the influence of area-level factors on adolescent suicide and to determine which variables differ according to age and sex.

METHODS

We selected variables that were available for collection through an online database from 2005 to 2015 in the Korean Statistical Information Service and the Korea Labor Institute. We used administrative districts of Korea in 2017 for geographical classification. We examined the relationships between regional suicide rates and area-level variables in male and female subjects aged 10-14 years and 15-19 years. In addition, we analyzed area-level variables in adolescents aged 15-19 years according to sex.

RESULTS

Our findings indicated that several area-level variables affected adolescent suicide rates, varying according to age and sex. Economic problems were shown to be more associated with suicide in male adolescents than in female adolescents. On the other hand, social fragmentation and health services were shown to be more associated with suicide in females.

CONCLUSION

Suicide in adolescents was attributable to area-level factors such as economic status, social fragmentation, and community health services. By identifying area-level variables affecting adolescent suicide rates, we will be able to contribute to implement mental health policies related to adolescent suicide.

Refugees' admission to mental health institutions in Norway: Is there an ethnic density effect?

Some recent European research claims that immigrants settle in urban areas with low scores on level-of-living conditions and a high prevalence of health-risk factors, and that these settlement patterns adversely affect their health. Other studies question the association between immigrant segregation and area deprivation on one hand, and negative health outcomes on the other hand, and identify possible beneficial effects of segregation, specifically the ethnic density effect. This paper aims to explore the possible ethnic density effect among refugees, a sub-population that often appears relatively vulnerable compared with immigrants in general. The data comprise 30 871 individuals, aged 20-69, with an (post-1989) officially registered refugee status from six major countries, including Vietnam, Somalia, Iran, Iraq, Sri Lanka and Bosnia. Two outcomes are analysed, covering the 2008-2011 period - the probability of being admitted at least once to a mental health institution and the number of bed days during that period. The results show that all immigrant clusters have relatively high concentrations of negative level-of-living conditions. Despite this finding, refugees living in clusters tend to have less use of mental healthcare services. The results suggest that for most refugee groups, living in clusters has positive health outcomes. Many countries use settlement policies to direct the inflow of refugees away from immigrant-dense areas. Norway's settlement policy is no exception, aiming at a geographic dispersal of refugees to avoid the emergence of socially segregated urban ethnic communities. This paper discusses the relevance of such a policy for refugees' overall integration and level-of-living conditions.

Attempted suicide in Sri Lanka - An epidemiological study of household and community factors

BACKGROUND

An individual's suicide risk is determined by personal characteristics, but is also influenced by their environment. Previous studies indicate a role of contextual effects on suicidal behaviour, but there is a dearth of quantitative evidence from Asia.

METHODS

Individual and community level data were collected on 165,233 people from 47,919 households in 171 communities in rural Sri Lanka. Data were collected on individual (age, sex, past suicide attempts and individual socioeconomic position (SEP)) and household (household SEP, pesticide access, alcohol use and multigenerational households) level factors. We used 3-level logit models to investigate compositional (individual) and contextual (household/community) effects.

RESULTS

We found significant variation between households 21% (95% CI 18%, 24%) and communities 4% (95% CI 3%, 5%) in the risk of a suicide attempt. Contextual factors as measured by low household SEP (OR 2.37 95% CI 2.10, 2.67), low community SEP (OR 1.45 95% CI 1.21, 1.74), and community 'problem' alcohol use (OR 1.44 95% CI 1.19, 1.75) were associated with an increased risk of suicide attempt. Women living in households with alcohol misuse were at higher risk of attempted suicide. We observed a protective effect of living in multigenerational households (OR 0.53 95% CI 0.42, 0.65).

LIMITATIONS

The outcome was respondent-reported and refers to lifetime reports of attempted suicide, therefore this study might be affected by socially desirable responding.

CONCLUSIONS

Our study finds that contextual factors are associated with an individual's risk of attempted suicide in Sri Lanka, independent of an individual's personal characteristics.

Annual Research Review: Suicide among youth - epidemiology, (potential) etiology, and treatment

BACKGROUND

Suicide is a leading cause of death and a complex clinical outcome. Here, we summarize the current state of research pertaining to suicidal thoughts and behaviors in youth. We review their definitions/measurement and phenomenology, epidemiology, potential etiological mechanisms, and psychological treatment and prevention efforts.

RESULTS

We identify key patterns and gaps in knowledge that should guide future work. Regarding epidemiology, the prevalence of suicidal thoughts and behaviors among youth varies across countries and sociodemographic populations. Despite this, studies are rarely conducted cross-nationally and do not uniformly account for high-risk populations. Regarding etiology, the majority of risk factors have been identified within the realm of environmental and psychological factors (notably negative affect-related processes), and most frequently using self-report measures. Little research has spanned across additional units of analyses including behavior, physiology, molecules, cells, and genes. Finally, there has been growing evidence in support of select psychotherapeutic treatment and prevention strategies, and preliminary evidence for technology-based interventions.

CONCLUSIONS

There is much work to be done to better understand suicidal thoughts and behaviors among youth. We strongly encourage future research to: (1) continue improving the conceptualization and operationalization of suicidal thoughts and behaviors; (2) improve etiological understanding by focusing on individual (preferably malleable) mechanisms; (3) improve etiological understanding also by integrating findings across multiple units of analyses and developing short-term prediction models; (4) demonstrate greater developmental sensitivity overall; and (5) account for diverse high-risk populations via sampling and reporting of sample characteristics. These serve as initial steps to improve the scientific approach, knowledge base, and ultimately prevention of suicidal thoughts and behaviors among youth.

The area level association between suicide, deprivation, social fragmentation and population density in the Republic of Ireland: a national study

PURPOSE

Numerous studies have examined the ecological relationship between suicide and area level determinants such as deprivation and social fragmentation. In Ireland, there is considerable geographic variation in the rates of suicide. However, there is a dearth of Irish studies investigating the geographic variability of suicide.

METHODS

The Irish Central Statistics Office (CSO) provided data relating to all deaths by suicide and deaths of undetermined intent that occurred from 2009 to 2011. Negative binomial regression was used to examine the relationship between area level suicide rates and measures of deprivation, social fragmentation and population density that were taken from the 2011 National Census.

RESULTS

Overall deprivation had the strongest independent effect on small-area rates of suicide, with the most deprived areas showing the greatest risk of suicide (risk ratio = 2.1; 95 % CI 1.70-2.52). Low population density (rurality) was associated with an increased risk suicide in males across both age groups and among females in the older 40-64-year age group. Conversely, a weak association between high population density (urbanicity) and increased suicide risk was found among females in the 15-39-year age group. Associations with social fragmentation only became apparent in the sub group analysis. Social fragmentation was associated with an elevated risk of suicide in the older 40-64 age group, with this effect being most pronounced among females.

CONCLUSION

The findings of this study demonstrate marked geographical inequalities in the distribution of suicide in Ireland and highlight the importance of targeting suicide prevention resources in the most deprived areas.

Childhood household dysfunction, school performance and psychiatric care utilisation in young adults: a register study of 96 399 individuals in Stockholm County

BACKGROUND

Exposure to childhood household dysfunction increases the risk of psychiatric morbidity. Although school performance also has been linked with psychiatric morbidity, limited research has considered school performance as a mediating factor. To address this gap in the literature, the current register study examined whether school performance mediates the association between childhood household dysfunction (experienced between birth and age 14 years) and psychiatric care utilisation in young adulthood.

METHODS

We used a Swedish cohort of 96 399 individuals born during 1987-1991. Indicators of childhood household dysfunction were familial death, parental substance abuse and psychiatric morbidity, parental somatic disease, parental criminality, parental separation/single-parent household, public assistance recipiency and residential instability. Final school grades from the 9th year of compulsory school were used to create five categories. Estimates of risk of psychiatric care utilisation (measured as inpatient, outpatient and primary care) after the age of 18 years were calculated as HRs with 95% CIs. Mediation was tested with the bootstrap approach.

RESULTS

Cumulative exposure to childhood household dysfunction was positively associated with psychiatric care utilisation. Specifically, individuals exposed to three or more indicators with incomplete school grades had the highest risk (HR=3.7 (95% CI 3.3 to 4.1) after adjusting for demographics), compared to individuals exposed to no indicators with highest grades. School performance was found to mediate the relationship.

CONCLUSIONS

Our findings suggest that future efforts to prevent or mitigate the negative effects of childhood household dysfunction on psychiatric morbidity may benefit from integration of strategies that improve school performance among vulnerable youth.