Stress exposure is central to theories of suicide. To advance understanding of the relation between stress and suicide, we examined whether specific, theoretically-pertinent life stressors were differentially related to suicidal thinking versus suicidal behaviors among hospitalized adolescents. Participants were 197 (144 female) adolescents aged 13 to 19 years old (M = 15.61, SD = 1.48) recruited from an acute residential psychiatric treatment program. Participants were categorized into mutually exclusive groups: psychiatric controls (n = 38) with no lifetime history of suicide ideation or suicide attempts, suicide ideators (n = 99) with current ideation and no lifetime attempts, and suicide attempters (n = 60) with a lifetime history of suicide ideation and at least one attempt in the past month. Adolescents completed the Stress and Adversity Inventory for Adolescents (Adolescent STRAIN), which assessed life events and chronic difficulties occurring in five social-psychological categories: Interpersonal Loss, Physical Danger, Humiliation, Entrapment, and Role Change/Disruption. Additionally, they completed a structured interview and symptom questionnaires to capture concurrent psychopathology. 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. These effects persisted when analyses were restricted to single attempters and when events following the most recent attempt were excluded. The findings elucidate potential social-environmental triggers of suicide. Ultimately, this may improve the identification of ideators most likely to make an attempt, enabling the deployment of targeted early interventions.
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We conducted all analyses with (n = 38) and without (n = 34) the PCs who had non-zero BSSI scores; these analyses yielded very similar results and the overall conclusions are identical. We report results using all PCs given: (a) prior empirical work using this BSSI cut-off and (b) the small sample size and limited statistical power.
The Adolescent STRAIN also assesses the perceived stressfulness of each endorsed stressor (i.e., “How stressful or threatening was this for you?”), and scores range from 1 (very slightly or not at all) to 5 (extremely). Perceived stressor severity scores are computed by summing severity ratings for each stressor that fall into a given category (e.g., Interpersonal Loss events). Counts and perceived severity scores in each category were very strongly correlated (rs > 0.83, ps < 0.001). The pattern of results obtained was identical when we re-ran analyses using perceived severity instead of counts, and these results are available from the first author by request.
Bivariate associations among clinical covariates included in the models ranged from small and non-significant (r = 0.02, p = 0.76) to moderate (r = 0.68, p < 0.001). However, all fell well below the most commonly used cut-off for assessing potential problems with multi-collinearity (i.e., r = 0.80; Tabachnick and Fidell 2013). Nonetheless, we re-ran all models while removing number of psychiatric disorders, as the correlation between this variable and the presence/absence of an anxiety disorder was the largest. However, the pattern of results was unchanged.
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This research was supported by the National Institutes of Health (K08 MH103443 to GMS and K23 MH097786 to RPA), the Brain and Behavior Research Foundation (NARSAD Young Investigator Awards to JGS  and GMS ), the American Foundation for Suicide Prevention (PRG-1-140-15 to JGS), Harvard Medical School (Kaplen Fellowship on Depression and Livingston Award to JGS), the Society in Science Branco Weiss Fellowship (GMS), the Tommy Fuss Fund (RPA), and the Simches Fund (RPA).
Conflict of Interest
The authors declare that they have no conflicts of interest.
Ethics approval for the study (Protocol #: 2012P000780) was obtained from the Partners Human Ethics Research Committee, the Institutional Review Board that oversees research at McLean Hospital and Harvard Medical School. All procedures were in line with the 1964 Helsinki declaration and its later amendments.
Informed consent was obtained from all individual participants included in the study.
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Stewart, J.G., Shields, G.S., Esposito, E.C. et al. Life Stress and Suicide in Adolescents. J Abnorm Child Psychol 47, 1707–1722 (2019). https://doi.org/10.1007/s10802-019-00534-5
- Stress exposure
- Ideation-to-action frameworks