Life Stress and Suicide in Adolescents

In the paper

“Controlling for demographic and clinical covariates, only Interpersonal Loss events distinguished attempters from psychiatric controls (OR = 2.27) and ideators (OR = 1.49); no events or difficulties differentiated ideators from controls.”

In the paper

“First, these analyses showed that, although age and sex were correlated with some of the STRAIN variables, the effects observed were not moderated by demographic factors in any case.”

In the paper

“All measures of psychiatric symptoms were moderately and significantly associated, and correlations between depression symptoms and the other four variables were particularly high (rs = 0.54–0.65, ps< 0.001).”

In the paper

“As expected, the groups also differed in residualized suicide ideation severity, F(2, 194)= 17.20, p < 0.001, ηp2 = 0.15. PCs reported less severe suicide ideation than both SIs (p < 0.001, d = 1.21) and SAs (p < 0.001, d = 0.94), but the latter two groups did not significantly differ (p = 0.634, d = 0.20).”

In the paper

“and higher life event counts were uniquely associated with being a SA relative to both a PC, b = 1.10, SE = 0.37, χ2[1, N = 175] = 9.07, p = 0.003, OR = 3.02, CI [1.47, 6.19],”

In the paper

“None of the other chronic difficulty variables were significant in the model, χ2s [2, N = 197] < 5.39, ps > 0.067.”

In the paper

“Last, the effect of Interpersonal Loss stressors was specific to acute life events and no category of chronic difficulty exposure was associated with STB group after adjusting for participants’ psychiatric characteristics.”

In the paper

“For diagnostic indices, there were group differences in rates of endorsing any mood disorder and any anxiety disorder; in both cases, SI and SA adolescents had higher rates of these diagnoses than PCs but did not significantly differ from one another.”

In the paper

“Rates of physical and sexual abuse differed across the groups, and the SA group reported higher rates than both PC and SI adolescents.”

In the paper

“In terms of the residualized symptom scores, groups significantly differed in residualized hopelessness, F(2, 194) = 5.51, p = 0.005, ηp2 = 0.05, such that SI adolescents reported more severe hopelessness than PCs (p = 0.003, d = 0.68), but all other pairwise comparisons were non-significant.”

In the paper

“The adjusted model remained significant, χ2[16, N = 197] = 160.46, p < 0.001.”

In the paper

“In doing so, we found that chronic Interpersonal Loss (e.g., ongoing arguments with partner; long-term separation from a parent) differentiated attempters and ideators from psychiatric controls but not from one another.”

In the paper

“Our sample reported more severe suicide ideation than excluded participants and may represent a subset of youth in the treatment program with particularly severe symptoms.”

In the paper

“Last, adolescents in the present sample were recruited from an intensive residential treatment program. They had severe psychiatric symptoms, complex and often unsupportive peer, family, and/or academic environments, and very high rates of STBs (see also Stewart et al. 2017b, c; Vergara et al. 2019).”

What the sources say

• Not checked yetcites Stewart et al. 2017b, c
• Not checked yetcites Vergara et al. 2019 source

In the paper

“The factors that differentiated ideators and attempters—namely, Interpersonal Loss events, the presence of abuse, and depression”

In the paper

“Contemporary ideation-to-action frameworks posit that stress exposure contributes to both the development and worsening of suicide ideation, as well as to the escalation from ideation to attempts (Klonsky et al. 2018).”

What the sources say

• Not checked yetcites Klonsky et al. 2018 source

In the paper

“Life stress is central to virtually all major theories of suicide (see O’Connor and Nock 2014).”

What the sources say

• Not checked yetcites O’Connor and Nock 2014

In the paper

“First, although ideation-to-action theories of suicide make assumptions about the types of stressors most implicated in STBs (e.g., Klonsky et al. 2018), these forms of stress are rarely explicitly measured”

What the sources say

• Not checked yetcites Klonsky et al. 2018 source

In the paper

“In contrast, the Integrated Motivational Volitional Theory of Suicide (IMV; O’Connor et al. 2016) proposes that entrapment (i.e., feelings of inescapable defeat) is essential to the development of suicide ideation, and for some, is brought on by external circumstances (e.g., caring for a chronically ill loved one).”

What the sources say

• Not checked yetcites O’Connor et al. 2016

In the paper

“General stressful life events are included among the IMV’s volitional moderators—a set of environmental (e.g., stressors), psychological (e.g., mental imagery), social (e.g., exposure to a loved one’s suicidal behavior), and physiological (e.g., pain tolerance) variables that facilitate or impede the transition from ideation to attempts.”

What the sources say

• Not checked yetcites O’Connor et al. 2016

In the paper

“Finally, all theories posit that for suicide ideation to progress to an attempt, one must have the capability to enact lethal self-harm.”

In the paper

“The SITBI has demonstrated good reliability and convergent validity in prior studies (Nock et al. 2007).”

What the sources say

• Not checked yetcites Nock et al. 2007 source

In the paper

“The loss of interpersonal relationships may reduce connectedness, and thus, the 3ST insinuates such losses may be implicated in attempts among ideators.”

In the paper

“while the IMV proposes that any form of stress might facilitate the transition from ideation to attempts.”

In the paper

“That said, current understanding of the role stressors play in many psychiatric disorders (e.g., depression; see Hammen 2018 for a review), is founded on cross-sectional studies employing rigorous stress assessments, well-characterized comparison groups, and clearly-defined outcomes (e.g., a major depressive episode).”

What the sources say

• Not checked yetcites Hammen 2018 source

In the paper

“Overall, suicide attempters may experience more stressful life events than ideators, especially interpersonal conflicts and potentially lethal physical danger (e.g., violent trauma).”

In the paper

“Excluded participants reported higher rates of physical abuse than included participants, χ2[1, N=340] =4.77, p = 0.029, Φ = 0.12.”

In the paper

“The SITBI and BSSI criteria have been used to classify STB groups in several prior studies (e.g., Stewart et al. 2017b; Stewart et al. 2017c; Vergara et al. 2019).”

What the sources say

• Not checked yetcites Stewart et al. 2017b
• Not checked yetcites Stewart et al. 2017c
• Not checked yetcites Vergara et al. 2019 source

In the paper

“Interviewers were research assistants or graduate students who received minimum 25 h of training (e.g., didactics, mock-interviews) and ongoing supervision.”

In the paper

“Finally, the core social-psychological characteristics showed significant associations with psychiatric symptom severity (rs = 0.15–0.40, ps < 0.01), although the magnitude of these associations varied greatly across the different stressor categories, thus indicating that stressors with certain social-psychological characteristics may be differentially linked to certain symptoms (Slavich et al. 2”

What the sources say

• Not checked yetcites Slavich et al. 2019

In the paper

“For instance, the ITS suggests that life events involving interpersonal loss and/or humiliation are involved in developing the desire to die, a necessary precursor of an attempt”

In the paper

“The Three-Step Theory of Suicide (3ST; Klonsky and May 2015) proposes that general life stress contributes to proximal states (i.e., psychological pain and hopelessness) necessary for developing ideation.”

What the sources say

• Not checked yetcites Klonsky and May 2015 source

In the paper

“Broadly defined interpersonal stressors appear in all theories, but each framework also makes distinct predictions about the specific types of stressors that facilitate: (a) developing suicide ideation and (b) attempts among ideators.”

In the paper

“In defining our PC and SI groups, we used a cutoff of 4 or greater on the BSSI to indicate clinically significant suicide ideation, which is consistent with guidelines for adolescent psychiatric patients (Holi et al. 2005) and prior research concucted with adolescent psychiatric inpatients (e.g., Stewart et al. 2017b, c).”

What the sources say

• Not checked yetcites Holi et al. 2005 source
• Not checked yetcites Stewart et al. 2017b, c

In the paper

“Stressor count was also associated with a variety of psychiatric indices (e.g., depression; anxiety; anhedonia; number of diagnoses) and physical health complaints (rs = 0.18–0.47), and these associations were robust while controlling for participant demographics (βs = 0.16–0.48, all ps < 0.006).”

What the sources say

• Not checked yetcites Slavich et al. 2019

In the paper

“Among leading suicide theories, the ITS has received the most empirical attention (and, by extension, support; see Chu et al. 2017)”

What the sources say

• Not checked yetcites Chu et al. 2017 source

In the paper

“However, Stone and colleagues found an association between dependent life events and subsequent attempts among females, though this effect was not robust when controlling for participants’ suicide attempt history.”

What the sources say

• Not checked yetcites Stone et al. 2014 source

In the paper

“Exposure to war and sexual victimization (Stein et al. 2010) and being the victim of violence or threats (Borges et al. 2008) have also been associated with greater odds of subsequent attempts among ideators, in adult and adolescent samples, respectively.”

What the sources say

• Not checked yetcites Stein et al. 2010 source
• Not checked yetcites Borges et al. 2008 source

In the paper

“Suicide capability is multi-determined, but all theories suggest that life events characterized by pain, danger, and/or fear (e.g., being in a physical fight) may contribute to acquiring suicide capability.”

In the paper

“The former approach precludes determining whether certain types of stressors are more strongly related to STBs than others and the latter limits the ability to conduct comparative analyses and reduces statistical power, since base rates for experiencing particular stressors are lower for more narrowly defined stress categories (see Liu and Miller 2014).”

What the sources say

• Not checked yetcites Liu and Miller 2014 source

In the paper

“Furthermore, lifetime stressor count was associated with significant additional explained variance in these outcomes while controlling for other stress measures (ΔR2s = 0.013–0.060), thus highlighting the incremental predictive validity of the Adolescent STRAIN above and beyond other commonly used instruments for assessing life stress.”

What the sources say

• Not checked yetcites Slavich et al. 2019

In the paper

“Similarly, Pettit and colleagues (Pettit et al. 2011) focused on chronic difficulties and found that greater chronic stress exposure predicted suicide ideation but not attempts among adolescent inpatients.”

What the sources say

• Not checked yetcites Pettit et al. 2011 source

In the paper

“Most (n = 34, 89.47%) of the PCs reported no current suicide ideation (BSSI = 0).”

In the paper

“The MINI-KID has high concordance with gold-standard diagnostic interviews and is a reliable assessment of psychiatric disorders in adolescent outpatients (Sheehan et al. 2010).”

What the sources say

• Not checked yetcites Sheehan et al. 2010 source

In the paper

“Included participants had higher BSSI scores as compared to excluded participants, t(338) = 2.25, p = 0.025, d = 0.25.”

In the paper

“The classification system that designates which stressor falls into which category was created during the initial development and validation of the STRAIN and was informed by an exhaustive review of the life stress literature, the structure of gold-standard stress assessment instruments, and consultations with stress assessment experts (see Slavich and Shields 2018).”

What the sources say

• Not checked yetcites Slavich and Shields 2018 source

In the paper

“Higher Adult STRAIN scores have also been associated with worse mental and physical health, as well as poorer cognitive, biological, clinical functioning across several different studies and distinct health contexts (e.g., Bower et al. 2014; Cuneo et al. 2017; Dooley et al. 2017; Goldfarb et al. 2017; Lam et al. 2019; Shields et al. 2017a, b; Slavich and Shields 2018; Toussaint et al. 2016).”

What the sources say

• Not checked yetcites Bower et al. 2014 source
• Not checked yetcites Cuneo et al. 2017 source
• Not checked yetcites Slavich and Shields 2018 source

In the paper

“However, community research is not well suited to determine whether stress exposure differentiates ideators from attempters because: (a) suicide attempters often report higher rates of psychopathology”

• Also stated in: § Life Stress: Suicide Ideators Versus Suicide Attempters · plain

  “and (b) there are low base rates of STBs, which limits the clinical significance of results with respect to informing prevention and interventions.”

In the paper

“Ultimately, this may improve the identification of ideators most likely to make an attempt, enabling the deployment of targeted early interventions.”

In the paper

“Finally, Miller and colleagues (Miller et al. 2017) also found that higher than usual chronic strain predicted suicide ideation and was prospectively associated with suicidal behavior among female adolescents. However, the latter effect only occurred among those reporting prior abuse.”

What the sources say

• Not checked yetcites Miller et al. 2017 source

In the paper

“First, they show that exposure to acute Interpersonal Loss is specifically related to attempts, and that this association is unlikely due to more severe ideation.”

In the paper

“Interpersonal relationships are paramount in adolescence and threats to these social bonds may be uniquely potent precipitants of adolescent suicide (Whitlock et al. 2014).”

What the sources say

• Not checked yetcites Whitlock et al. 2014 source

In the paper

“The reliability of BHS items was excellent, α = 0.91.”

In the paper

“This approach was used to reduce the likelihood of overfitting primary models by including many moderately correlated predictors.”

In the paper

“MASC items demonstrated excellent reliability, α = 0.92.”

In the paper

“The internal consistency of the SHAPS was good, α = 0.88.”

In the paper

“Ideation-to-action theories of suicide stipulate that a variety of stressful experiences contribute to the development of suicide ideation (Joiner 2005; O’Connor et al. 2016).”

What the sources say

• Not checked yetcites Joiner 2005
• Not checked yetcites O’Connor et al. 2016

In the paper

“Last, we conducted two sensitivity analyses aimed at limiting the confounding effect of temporal overlap between life stress and suicide attempts.”

In the paper

“The reliability of items in the physical and sexual abuse subscales was good, α = 0.84, and excellent, α = 0.94, respectively.”

In the paper

“The CES-D items had excellent internal consistency, α = 0.94.”

In the paper

“Depression is among the strongest correlates of suicide ideation, and in adolescents, the presence of a unipolar mood disorder increases odds of subsequent suicide ideation by more than 4-fold (Nock et al. 2013).”

What the sources say

• Not checked yetcites Nock et al. 2013 source

In the paper

“As participants retrospectively recalled stressors, there are potential concerns that stressors were missed or inaccurately reported (i.e., recall bias).”

In the paper

“Third, notwithstanding its considerable strengths (e.g., scalability, behaviorally-anchored probe questions, branching logic), the Adolescent STRAIN does not guide participants on how to interpret items, which could increase variability attributable to their idiosyncratic understanding of what constitutes a stressor (see Harkness and Monroe 2016).”

What the sources say

• Not checked yetcites Harkness and Monroe 2016 source

In the paper

“As interpersonal relationships are salient in adolescence (Steinberg and Morris 2001) and youth may be more sensitive to negative social experiences (Platt et al. 2013), it is conceivable that Interpersonal Loss is more strongly linked to STBs in adolescence.”

What the sources say

• Not checked yetcites Steinberg and Morris 2001 source
• Not checked yetcites Platt et al. 2013 source

In the paper

“First, data were cross-sectional, and despite taking steps to enhance confidence in the direction of the effects, causality cannot be assumed.”

In the paper

“Like many other stress measures, it provides data on whether certain stressors have occurred during a given time frame, but does not employ an independent panel of raters who generate objective, contextually based ratings of stressor severity.”

In the paper

“Chronic stressors, particularly those involving Interpersonal Loss, may be associated with adolescent suicide ideation directly and/or indirectly via their relations with psychiatric symptoms.”

In the paper

“Furthermore, adolescent attempters may experience a higher rate of dependent stressful life events—that is, events partly influenced by their own characteristics—which might produce differences between attempters and non-attempters both prior to and following index attempts.”

In the paper

“These concerns are tempered by (a) the STRAIN’s focus on major stressors over the past year, which studies show can be recalled accurately (Johnson 2005; Paykel 1997) and (b) controlling for psychiatric symptoms (e.g., depression) that may bias recall.”

What the sources say

• Not checked yetcites Johnson 2005 source
• Not checked yetcites Paykel 1997 source

In the paper

“Fourth, the variables used in our models were measured using different time frames (e.g., stressors over the past year, past month attempts, symptoms in the past week).”

In the paper

“Notably, interpersonal stress is a potent and reliable predictor of major depressive episodes (Hammen 2018; Harkness et al. 2010)”

What the sources say

• Not checked yetcites Hammen 2018 source
• Not checked yetcites Harkness et al. 2010 source

In the paper

“In contrast, financial- and employment-related stress may be most relevant for predicting suicide in middle adulthood (DeJong et al. 2010; Innamorati et al. 2008), while health-related events and difficulties may play a more central role in suicide for older adults, particularly through their effects on cognitive-affective states like perceived burdensomeness (e.g., Cukrowicz et al. 2011).”

What the sources say

• Not checked yetcites DeJong et al. 2010 source
• Not checked yetcites Innamorati et al. 2008 source
• Not checked yetcites Cukrowicz et al. 2011 source

In the paper

“and focuses on particular interpersonal problems by equipping adolescents with communication and problem solving skills to bolster coping.”

What the sources say

• Not checked yetcites Mufson et al. 2004 source

In the paper

“The ITS, IMV, and 3ST all suggest that experiences involving pain, danger, and/or fear may contribute to suicide capability, and consequently, differentiate suicide attempters from non-attempters.”

In the paper

“Although depression is generally more strongly associated with suicide ideation than attempts (Nock et al. 2013)”

What the sources say

• Not checked yetcites Nock et al. 2013 source

In the paper

“The number and type of stressful life events preceding major depressive episodes vary across the lifespan (Harkness et al. 2010), but similar research has not been conducted in the context of STBs.”

What the sources say

• Not checked yetcites Harkness et al. 2010 source

In the paper

“depressed individuals generate interpersonal stressors that are at least partly related to their behaviors or characteristics (Hammen 2018; Harkness and Stewart 2009).”

What the sources say

• Not checked yetcites Hammen 2018 source
• Not checked yetcites Harkness and Stewart 2009 source

In the paper

“Although MINI-KID diagnoses likely preceded attempts (and, in many cases, life stressors), precise dates of onset were not collected and furthermore, as we did not have consent to record diagnostic interviews, the inter-rated reliability of MINI-KID diagnoses was not examined.”

In the paper

“However, it is important to note that the present study did not measure access to lethal means, suicidal intent, or other critical determinants of suicide attempts.”

In the paper

“Therefore, these results may not necessarily generalize to other youth in outpatient or community treatment settings, or to those exhibiting less severe psychiatric symptoms.”

In the paper

“The factors that differentiated ideators and attempters—namely, Interpersonal Loss events, the presence of abuse, and depression—may also point toward interventions that may be most helpful in reducing suicide risk in youth.”

In the paper

“Current psychiatric symptoms were explicitly chosen to control for state effects on reporting life stress.”

In the paper

“Also, to enhance efficiency, the Adolescent STRAIN only obtains severity and stress exposure timing data for the most severe occurrence for stressors experienced multiple times; consequently, we may have underestimated effects for youth who experienced the same stressor multiple times.”

In the paper

“Given DBT’s focus on managing intense negative affect, particular skills (e.g., distress tolerance) may be useful for managing acute suicide risk among youth with trauma histories and recent Interpersonal Loss events.”

In the paper

“Studies testing the ITS in youth have found modest relations between acquired capability and suicide attempts and a minority of studies have failed to find this association (see Stewart et al. 2017a).”

What the sources say

• Not checked yetcites Stewart et al. 2017a