Suicide is the second leading cause of death among adolescents aged 10-24 in the US. Although many risk factors for suicidal behaviors have been identified, little is known about the factors that differentiate adolescents who only attempt suicide from those who only think about or plan suicide, as suggested by “ideation to action” framework. Existing research under this framework has strongly relied on psychological risks factors, while few have explored the influences of individual and cumulative health risk behaviors (HRBs) on distinguishing suicide attempters and ideators. Identifying HRBs that contribute to the distinction has clinical implication for screening adolescents at risk of suicide, and designing interventions tailored to adolescents with specific HRBs.
To address the knowledge gap, the overall purpose of this study is to examine the associations between individual and cumulative HRBs and different suicidal behaviors profiles (guided by ideation-to-action framework) among adolescents. Given the racial/ethnic and gender disparities in the risks of engaging in HRBs and suicidal behaviors, we also investigated the racial/ethnic and gender differences regarding the associations between HRBs and suicidal behaviors profiles.
Data and samples: Data were derived from 2,229 students (65.01% female, Mage= 16.02±1.28) in grades 9–12 from the 2017 National Youth Risk Behavior Survey (YRBS), a nationally representative sample.
Measures: Suicidal behaviors were measured by self-reported suicidal ideation, suicide plan, and suicide attempt. Responses were then used to further categorize four groups: ideation only, ideation and plan (without attempt), attempt with ideation/plan, and attempt only. Thirteen indicators of HRBs, including diet, exercise, sleep, media, and substance use were measured individually and used to create a cumulative HRBs index (ranges from 0-13). Demographic variables included race/ethnicity, gender, and age. Depressive affect was assessed using one question on sadness/hopelessness.
Analysis: Multinomial logistic regression adjusting for complex survey design was used to examine the associations between individual and cumulative HRBs that differentiated suicidal ideation from plan and attempts. Analyses were conducted among the total sample and then stratified by gender. Interactions among race/ethnicity, gender, and cumulative HRBs were included to investigate moderation effects.
Compared with adolescents with suicidal ideation only, females adolescents who smoked cigarette (ORadj=2.37, 95%CI= [1.12, 5.01]) and used marijuana (ORadj=2.02 [1.21, 3.37]) had higher odds of attempting suicide along with ideation/plan. For males, not participating in team sports was related to 7.42 higher odds of attempting suicide without reporting thoughts/plan. Greater cumulative HRBs were linked to higher risk of attempting suicide with reported ideation/plan (ORadj=1.08 [1.01, 1.16]). Significant moderation effect was revealed: With increasing cumulative HRBs, Black boys and other-race boys were less likely to have ‘suicide attempt only’ than ‘ideation only’ (ORadj=0.53 [0.31, 0.90], 0.23 [0.07, 0.83], respectively).
Conclusion and Implications
Significant racial/ethnic and gender disparities are observed in the associations of HRBs that differentiated adolescents in suicidal thoughts, plan, and attempts. With greater cumulative HRBs, Black and other-race males had greater risks in thinking about suicide only. Social work professionals shall address intersectionality when preventing and intervening suicide among adolescents with different types and levels of HRBs.