The associations between suicidal ideation and attempt and anxiety symptoms and the demographic, psychological, and social moderators in Taiwanese adolescents.

This article was downloaded by: [Adams State University] On: 23 October 2014, At: 13:44 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Archives of Suicide Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usui20

The Associations between Suicidal Ideation and Attempt and Anxiety Symptoms and the Demographic, Psychological, and Social Moderators in Taiwanese Adolescents Cheng-Fang Yen , Chien-Yu Lai , Chih-Hung Ko , Tai-Ling Liu , TzeChun Tang , Yu-Yu Wu & Pinchen Yang Accepted author version posted online: 19 Dec 2013.Published online: 28 Feb 2014.

To cite this article: Cheng-Fang Yen , Chien-Yu Lai , Chih-Hung Ko , Tai-Ling Liu , Tze-Chun Tang , YuYu Wu & Pinchen Yang (2014) The Associations between Suicidal Ideation and Attempt and Anxiety Symptoms and the Demographic, Psychological, and Social Moderators in Taiwanese Adolescents, Archives of Suicide Research, 18:1, 104-116, DOI: 10.1080/13811118.2013.824826 To link to this article: http://dx.doi.org/10.1080/13811118.2013.824826

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions

Downloaded by [Adams State University] at 13:44 23 October 2014

Archives of Suicide Research, 18:104–116, 2014 Copyright © International Academy for Suicide Research ISSN: 1381-1118 print/1543-6136 online DOI: 10.1080/13811118.2013.824826

The Associations between Suicidal Ideation and Attempt and Anxiety Symptoms and the Demographic, Psychological, and Social Moderators in Taiwanese Adolescents Cheng-Fang Yen, Chien-Yu Lai, Chih-Hung Ko, Tai-Ling Liu, Tze-Chun Tang, Yu-Yu Wu, and Pinchen Yang The objectives of this study were to examine the associations between suicidal ideation and attempt and anxiety symptoms and the moderators in 5,027 Taiwanese adolescents. The associations between suicidal ideation and attempt and anxiety symptoms on the Taiwanese version of the Multidimensional Anxiety Scale for Children (MASC-T) were examined using logistic regression analysis. The moderating effects of demographic (gender and age), psychological (problematic alcohol use, severe depressive symptoms, and low self-esteem), and social factors (bullying victimization, and low family function) on the associations were examined. Adolescents who had anxiety symptoms were more likely to have suicidal ideation and attempt than those who did not have anxiety symptoms. Bullying victimization had a moderating effect on the association between suicidal ideation and anxiety symptoms. Assessment of suicidal ideation and attempt should be routine practice among adolescents who present with anxiety symptoms. Keywords adolescent, anxiety, moderator, Multidimensional Anxiety Scale for Children, suicidal attempt, suicidal ideation

INTRODUCTION

aged 15–24 in Taiwan, second to accidents (Department of Health, Executive Yuan, Taiwan, 2011). The Ministry of Education and the Department of Health in Taiwan initiated the Campus Suicide Prevention Program, which aims to screen adolescent

Adolescent suicide is an important health issue around the world. The latest official report in 2010 indicated that suicide is the second leading cause of death for people

104


C.–F. Yen et al.

students at high risk of suicide and provide them with the necessary counseling to prevent suicide (Department of Education, Executive Yuan, Taiwan, 2012). Research has found that most adolescent suicide attempts were preceded by suicidal ideation (Klimes-Dougan, Free, Ronsaville et al., 1999), and thus not only attempted suicide but also suicidal ideation needs to be evaluated. It is necessary to examine the individual and environmental associated factors of suicidal ideation and attempt among adolescents to serve as an imperative index for a suicide prevention policy (Spirito, 2002). Mental disorders have been found to be one of the most important risk factors for suicide (Nock, Borges, Bromet et al., 2008). Anxiety disorders are highly prevalent in childhood and adolescence (Costello, Angold, Burns et al., 1996). However, the relationship between anxiety and adolescent suicidality has attracted less attention than that between depression and adolescent suicidality (Hill, Castellanos, & Pettit, 2011). Research has found that clinicians do not routinely investigate the suicide risk in patients with anxiety disorders, leading to underreporting of suicidal ideation and attempt in these patients (Noyes, 1991). Mattison (1988) and Hill, Castellanos, and Pettit (2011) published systemic reviews of the results of previous studies on the relationship between anxiety and suicidal ideation and attempt and determined that definitive conclusions could not be established, though it appeared that some associations between anxiety and suicidal ideation and attempt were present. Several issues regarding the relationships between suicidal ideation and attempt and anxiety need further study. First, the association between anxiety and suicidal behaviors may be influenced or be accounted for by a third variable or set of variables (Hill, Castellanos, & Pettit, 2011). Comorbid depressive symptoms are a factor that has been examined in previous studies regarding its effect on the association between anxiety and suicidal

behaviors; however, the results of previous studies on the role of depression were mixed (Hill, Castellanos, & Pettit, 2011). The role of depressive symptoms in the associations between anxiety and suicidal ideation and attempt in adolescents needs further study. It is especially noteworthy that previous studies only considered the third-variable effect of depression, demographic characteristics, and other psychiatric diagnoses on the association between anxiety and suicidality in children and adolescents (Hill, Castellanos, & Pettit, 2011). One study examined the role of alcohol/ drug use in the association between panic attacks and suicide attempts in mid-adolescence (Pilowsky, Wu, & Anthony, 1999), and another study examined the role of hopelessness in the association between anxiety and adolescent suicide behaviors (Thompson, Mazza, Herting et al., 2005). Adolescent development is the result of multi-systemic interactions (Lerner & Castellino, 2002), and thus several demographic, psychological, and social factors have found to be associated with adolescent suicidality. For example, in addition to depression, previous studies have also found that the female gender (Goldacre & Hawton, 1985; Tang, Ko, Yen et al., 2009; Wang, Lai, Hsu et al., 2011), older age (Foley, Goldston, Costello et al., 2006), lower self-esteem (Tang, Ko, Yen et al., 2009; Wang, Lai, Hsu et al., 2011; Wilburn & Smith, 2005), problematic alcohol drinking (Giner, Carballo, Guija et al., 2007; Tang, Ko, Yen et al., 2009), poor family function (Kerr, Preuss, & King, 2006; Tang, Ko, Yen et al., 2009), and bullying victimization (Kim & Leventhal, 2008; Tang, Ko, Yen et al., 2009; Wang, Lai, Hsu et al., 2011) are associated with adolescent suicidality. Further study is needed to determine whether these demographic, psychological, and social factors have moderating effects on the associations between suicidal ideation and attempt and anxiety in adolescents. If these factors have moderating

ARCHIVES OF SUICIDE RESEARCH

105


Suicidality and Anxiety Symptoms

effects, prevention and intervention programs for suicidality in anxious adolescents must take these factors into consideration. The aims of this study were to examine the relationships between suicidal ideation and attempt and anxiety symptoms and the moderating effects of demographic (gender and age), psychological (problematic alcohol use, severe depressive symptoms, and low self-esteem), and social factors (bullying victimization and low family function) on the associations between suicidal ideation and attempt and anxiety symptoms in a large, representative population of Taiwanese adolescents in the community. We hypothesized that after controlling for the effects of demographic, psychological, and social factors, anxiety symptoms are significantly associated with suicidal ideation and attempt in adolescents. Because of a lack of systemic studies on the moderators of the association between anxiety symptoms and suicidality in adolescents, we temporally hypothesized that there are demographic, psychological, and social moderators of the associations between suicidal ideation and attempt and anxiety symptoms. METHODS Participants

The Project for the Health of Children and Adolescents in Southern Taiwan was first conducted in 2004 and repeated every 5 years. The aims of this survey study were to evaluate the prevalence rates and correlates of mental health problems and risky behaviors of adolescents in southern Taiwan. The subjects in this study were enrolled from the 2009 Project for the Health of Children and Adolescents in Southern Taiwan, a research program studying the mental health status of children and adolescents living in four counties and three

106

metropolitan areas in southern Taiwan (Yen, Ko, Wu et al., 2010a). In 2009, there were 254,130 students in 205 junior high schools and 202,883 students in 143 senior high/vocational schools in this area. On the basis of the definitions of urban and rural districts in the Taiwan-Fukien Demographic Fact Book (Ministry of the Interior, 2002) and school and grade characteristics, a stratified random sampling strategy was used to ensure that there was proportional representation of districts, schools, and grades. Five junior high schools and five senior high/vocational schools were randomly selected from urban districts; similarly, five junior high schools and four senior high/ vocational schools were randomly selected from rural districts. The classes in these schools were further stratified into three levels based on grade in primary, junior high, and senior high/vocational school. Then, a total of 6,703 high school students in grades 7 through 12 were randomly selected based on the ratio of students in each grade. The Institutional Review Board (IRB) of Kaohsiung Medical University approved the study, allowing the use of passive consent from parents and students. Before conducting the study, we prepared a leaflet explaining the purpose and procedure of this study. Students took the leaflet home for their parents or main caretakers, who could telephone the researchers, write in a communications book, or ask their children directly to refuse to join the study. The students also had the right to refuse to participate in this study by returning blank questionnaires along with those from other students. Instruments

Suicidality. The 5-item questionnaire from the epidemiological version of the KiddieSchedule for Affective Disorders and Schizophrenia (K-SADS-E) (Puig-Antich & Chambers, 1978) was used to assess the

VOLUME 18 • NUMBER 1 • 2014


C.–F. Yen et al.

occurrence of four forms of suicidal ideation (items 1 to 4) and suicide attempt (item 5) in the preceding year (Tang, Ko, Yen et al., 2009). Each question elicited a “yes” or “no” answer. The Cohen’s kappa coefficient of agreement (κ) between participants’ selfreported suicide attempts and their parents’ reports was 0.541 (p < 0.001) (Tang, Ko, Yen et al., 2009). In this study, those who had a “yes” answer to any of the first four items and to the last item were classified as having suicidal ideation and suicidal attempt, respectively. Taiwanese Version of the Multidimensional Anxiety Scale for Children. The Taiwanese Version of the Multidimensional Anxiety Scale for Children (MASC-T) was used to evaluate the level of anxiety symptoms, including physical symptoms, harm avoidance, social anxiety, and separation/panic, in children and adolescents, with 39 items answered on a 4-point Likert scale (March, Parker, Sullivan et al., 1997; Yen, Yang, Wu et al., 2010b). Higher scores on the total MASC-T indicated more severe anxiety symptoms. The psychometrics of the MASC-T have been examined in a community sample of 12,536 Taiwanese children and adolescents across genders and ages, and the results of this examination have been described elsewhere (Yen, Yang, Wu et al., 2010b). In this study the total MASC-T score was used to represent participants’ severity of anxiety symptoms. CRAFFT Alcohol Abuse Screening Test. The self-reported CRAFFT Alcohol Abuse Screening Test (CRAFFT) was developed to assess problematic alcohol use in adolescents (Knight, Sherritt, Harris et al., 2003; Ko, Yen, Yen et al., 2008). Previous research (Knight, Sherritt, Harris et al., 2003) demonstrated that a cutoff score of 2 on the CRAFFT could be used to identify adolescents with an alcohol use disorder or with problematic alcohol use based on the Diagnostic and Statistical Manual of Mental

Disorders (DSM-IV) (American Psychiatric Association, 1994). In this study, we classified the adolescents with a score of 2 or more on the CRAFFT as the “problematic alcohol use” group. Mandarin Chinese Version of the Center for Epidemiological Studies-Depression Scale. The Mandarin Chinese Version of the Center for Epidemiological Studies-Depression Scale (MC-CES-D) used in this study was a 20-item self-administered questionnaire that used a 4-point evaluation scale to assess the frequency of depressive symptoms in the preceding week (Chien & Cheng, 1985; Radloff, 1977). Higher MC-CES-D scores indicated more severe depression. In this study, participants whose total MC-CES-D score was 1 SD higher than the mean of the whole study population (a score of 26) were classified as the group with severe depressive symptoms. Rosenberg Self-Esteem Scale. We used the Rosenberg Self-Esteem Scale (RSES) to evaluate adolescents’ level of self-esteem. The RSES contained ten 4-point items with good reliability and construct validity (Rosenberg, 1965). The scale yielded a single overall score of self-esteem, with high scores indicating high levels of self-esteem. Additionally, this scale previously has been used to evaluate the level of self-esteem of Taiwanese adolescents (Yen, Hsiao, Ko et al., 2010c). In this study, adolescents whose total RSES score was 1 SD lower than the mean of the whole study population (a score of 13) were classified as the group with low self-esteem. Chinese Version of the School Bullying Experience Questionnaire. The self-reported Chinese Version of the School Bullying Experience Questionnaire (C-SBEQ) was used to evaluate participants’ involvement in school bullying in the previous one year, with 16 items answered on a 4-point Likert scale, ranging from 0, indicating “never”; 1,


107



indicating “just a little”; 2, indicating “often”; to 3, indicating “all the time” (Kim, Koh, & Noh, 2001). The psychometrics of the C-SBEQ have been examined in Taiwanese adolescents, and the results of this examination have been described elsewhere (Yen, Kim, Tang et al., 2012). In this study, participants who answered 2 or 3 on any item among items 1 to 8 were identified as self-reported victims of bullying. Family APGAR Index. The Taiwanese version of the Family APGAR Index (APGAR; Chau, Hsiao, Huang et al., 1991) is based on the original version developed by Smilkstein (1978). The measure consists of five parameters of family functioning: Adaptability, Partnership, Growth, Affection, and Resolve. The 4-point response scales reflect frequency, ranging from never to always. A higher score indicates better family function. In this study, adolescents whose total APGAR score was 1 SD lower than the mean of the whole study population (a score of 11) were classified as the group with low family function. We also collected participants’ gender and age. In Taiwan, adolescents who are aged 12–14 years usually attend junior high schools, and those who are age 15 years or older attend senior high schools. Thus, we divided the participants using 15 years of age as the cutoff point. Statistical Analysis

Data analysis was performed using SPSS 15.0 statistical software (SPSS Inc., Chicago, IL, USA). First, logistic regression analyses were used to examine the associations of suicidal ideation and attempt with anxiety symptoms, gender, age, problematic alcohol use, significant depression, low selfesteem, being bullied, and low family function. Second, we used the standard criteria (Baron & Kenny, 1986) to examine whether the associations between suicidal ideation and attempt and anxiety symptoms were

108

different in terms of the participants’ gender, age, alcohol use, depressive symptoms, self-esteem, experience of being bullied, and family function. According to the criteria, moderation occurred when the interaction term for the predictor (anxiety symptoms) and the hypothesized moderator (gender, age, alcohol use, depressive symptoms, selfesteem, the experience of being bullied, and family function) were significantly associated with the dependent variable (suicidal ideation and attempt) after controlling for the main effects of both the predictors and hypothesized moderator variables. In this study, if anxiety symptoms and hypothesized moderators were significantly associated with suicidal ideation and attempt in the logistic regression analysis, the interactions (anxiety symptoms x hypothesized moderators) were further selected into logistic regression analysis to examine the moderating effects. We used the Wald χ2 to examine the significance, and a two-tailed p value of less than 0.05 was considered statistically significant. Meanwhile, the odds ratio (OR) and 95% confidence interval (CI) were used to estimate the effect size in the logistic regression analysis. RESULTS

A total of 6,445 students (96.2%) agreed to join this study. Of the 258 students who refused to join this study, 68 students refused based on their parents’ opinion, 128 returned blank questionnaires, and 62 were absent when the research assistants visited their classes. Each student completed the research questionnaire anonymously under the direction of research assistants in each classroom during school hours. All students received a gift worth 33 NT dollars (one US dollar) at the end of the assessment. A total of 5,027 students (78.0%) completed the research questionnaires without any omission. Of the 1,418 students who returned their questionnaires with omission, 38 had omissions in the questions regarding



C.–F. Yen et al.

suicidal ideation or attempt, 939 had any omission in the MASC-T, 26 had any omission in the questions regarding gender and age, and 328 had any omission in the CRAFFT, MC-CES-D, RSES, C-SBEQ, or APGAR. Those who had missing data in the questionnaires were more likely to be male ( χ2 = 13.689, p < 0.001) and be younger ( χ2 = 100.770, p < 0.001). The distributions of gender and age and the proportions of participants with suicidal ideation and attempt, problematic alcohol use, severe depression, low selfesteem, the experience of being bullied, and low family function in the 5,027 students who completed the research questionnaires are shown in Table 1. Of the participants, 1586 (31.5%) and 311 (6.2%) reported TABLE 1. Characteristics of the Participants (N = 5027) n (%) Gender Female Male Older age (15 years of age or older) No Yes Having suicidal ideation No Yes Having suicidal attempt No Yes Problematic alcohol use No Yes Severe depressive symptoms No Yes Low self-esteem No Yes Bullying victimization No Yes Low family function No Yes

2710 (53.9) 2317 (46.1) 2174 (43.2) 2853 (56.8) 3441 (68.5) 1586 (31.5) 4716 (93.8) 311 (6.2) 4373 (87.0) 654 (13.0) 4263 (84.8) 764 (15.2) 4304 (85.6) 723 (14.4) 3822 (76.0) 1205 (24.0) 4212 (83.8) 815 (16.2)

having suicidal ideation and attempt in the preceding year, respectively, and 830 (16.5%) participants reported severe anxiety symptoms. Of the 311 participants with suicidal attempt in the preceding year, 275 (88.4%) and 36 (11.6%) reported having and having no suicidal ideation in the preceding year, respectively. The mean severity of anxiety symptoms on the MASC-T was 38.3 (standard deviation = 15.5). The associations of suicidal ideation with anxiety symptoms, gender, age, problematic alcohol use, severe depressive symptoms, low self-esteem, the experience of being bullied, and low family function were examined by logistic regression analysis, as shown in Table 2. The results of Model I indicated that after controlling for the effects of other variables, more severe anxiety symptoms were significantly associated with suicidal ideation (Wald χ2 = 96.781, p < .001, OR = 1.024, 95% CI: 1.019–1.029). Because gender, age, problematic alcohol use, severe depressive symptoms, low selfesteem, the experience of being bullied, and low family function also were significantly associated with suicidal ideation, the interactions between anxiety symptoms and these variables were further selected into logistic regression analysis to examine their moderating effects (Model II). The results indicated that the interaction between anxiety symptoms and being bullied was significantly associated with suicidal ideation (Wald χ2 = 5.663, p < .05, OR = .988, 95% CI:.978–.998). We found that the association between suicidal ideation and anxiety symptoms was more significant in adolescents who had no experience of being bullied (Wald χ2 = 87.570, p < .001, OR = 1.028, 95% CI: 1.022–1.034) than in adolescents who had the experience of being bullied (Wald χ2 = 12.342, p < .001, OR = 1.015, 95% CI: 1.006–1.023). The associations of suicidal attempt with anxiety symptoms, gender, age, problematic alcohol use, severe depressive symptoms, low self-esteem, the experience of


109



TABLE 2. Association between Suicidal Ideation and Severe Anxiety Symptoms and the Moderators: Results of Logistic Regression Analysis

Model I Anxiety symptoms Male Older age Problematic alcohol use Severe depressive symptoms Low self-esteem Bullying victimization Low family function Model IIa Anxiety symptoms × Male Anxiety symptoms × Older age Anxiety symptoms × Problematic alcohol use Anxiety symptoms × Severe depressive symptoms Anxiety symptoms × Low self-esteem Anxiety symptoms × Bullying victimization Anxiety symptoms × Low family function

WALD X 2

OR

96.781∗∗∗ 12.156∗∗∗ 7.357∗∗ 64.735∗∗∗ 100.948∗∗∗ 65.800∗∗∗ 16.052∗∗∗ 57.649∗∗∗

1.024 .784 1.207 2.145 2.815 2.263 1.375 1.987

1.019–1.029 .684–.899 1.054–1.383 1.781–2.583 2.300–3.444 1.858–2.757 1.177–1.607 1.664–2.372

2.068

1.007

.998–1.016

2.032

1.007

.998–1.016

.585

1.005

.993–1.017

.508

1.005

.992–1.018

.216

1.003

.991–1.014

5.663∗

.988

.978–.998

.207

1.003

.991–1.014

95% CI OF OR

Note. a: Only variables of interaction are shown. ∗: < .05; ∗∗: < .01; ∗∗∗: < .001.

being bullied, and low family function examined by logistic regression analysis are shown in Table 3. The results of Model III indicated that after controlling for the effects of other variables, more severe anxiety symptoms were significantly associated with suicidal attempt (Wald χ2 = 5.710, p < .05, OR = 1.010, 95% CI: 1.002––1.018). Because gender, problematic alcohol use, severe depressive symptoms, low selfesteem, the experience of being bullied, and low family function also were significantly associated with suicidal attempt, the interactions between anxiety symptoms and these variables were further selected into logistic regression analysis to examine their moderating effects (Model IV). However, the associations between suicidal attempt and the variables of interactions were not

110

significant, which indicated that gender, problematic alcohol use, severe depressive symptoms, low self-esteem, the experience of being bullied, and low family function had no moderating effect on the association between suicidal attempt and anxiety symptoms. DISCUSSION

This study found that a high proportion of adolescents reported having suicidal ideation (31.5%) and attempt (6.2%) in the preceding year. The results indicate that it is important to screen suicidal ideation and attempt not only among adolescents visiting psychiatric service units but also among adolescents in the community. It is also noteworthy that most (88.4%) of the


C.–F. Yen et al.


TABLE 3. Association Between Suicidal Attempt and Severe Anxiety Symptoms and the Moderators: Results of Logistic Regression Analysis

Model III Anxiety symptoms Male Older age Problematic alcohol use Severe depressive symptoms Low self-esteem Bullying victimization Low family function Model IVa Anxiety symptoms × Male Anxiety symptoms × Problematic alcohol use Anxiety symptoms × Severe depressive symptoms Anxiety symptoms × Low self-esteem Anxiety symptoms × Bullying victimization Anxiety symptoms × Low family function

Wald X 2

OR

95% CI of OR

5.710∗ 23.250∗∗∗ 1.392 64.122∗∗∗ 32.085∗∗∗ 6.145∗ 5.657∗ 19.978∗∗∗

1.010 .524 .861 3.019 2.522 1.477 1.383 1.895

1.002–1.018 .403–.681 .672–1.104 2.304–3.957 1.831–3.474 1.085–2.010 1.059–1.807 1.432–2.509

.271

.996

.980–1.012

1.300

1.009

.993–1.026

.180

.996

.978–1.014

.159

1.004

.986–1.021

2.624

.987

.972–1.003

1.205

.991

.975–1.007

Note. a: Only variables of interaction are shown. ∗: < .05; ∗∗∗: < .001.

participants with suicidal attempt reported having suicidal ideation in the preceding year. Because most adolescent suicide attempts were preceded by suicidal ideation (Klimes-Dougan, Free, Ronsaville et al., 1999), it is necessary to evaluate not only attempted suicide but also suicidal ideation. This study found that after controlling for the effects of demographic, psychological, and social factors, more anxiety symptoms are significantly associated both with suicidal ideation and attempt among adolescents in the community. The results of previous studies on the associations between anxiety and suicidal ideation and attempt in community samples of adolescents were mixed. For example, the study of Foley, Goldston, Costello et al. (2006) found that anxiety disorders were not independent predictors of suicidal ideation or attempt,

whereas the study of Gould, King, Greenwald et al. (1998) found that the presence of any anxiety disorder was associated with an increased risk of suicidal ideation or attempt. The findings of this study suggest that anxiety symptoms are an independent correlate of suicidal ideation and attempt. Assessment of suicidal ideation and attempt should be routine practice among adolescents who present with anxiety symptoms. Clinicians may use anxiety symptoms for the screening examination when evaluating suicidal ideation and attempt among adolescents in the community. However, previous prospective studies examining the predicting effect of anxiety on the occurrence of suicide attempt are very few in number. A previous study on adolescent psychiatric inpatients found that anxiety disorders did not predict suicide attempts in the 5 years after discharge (Goldston, Daniel,


111



Reboussin et al., 1999). Further prospective study is needed to examine the predicting effect of anxiety on the occurrence of suicidality (Hill, Castellanos, & Pettit, 2011). Meanwhile, further study on whether active treatment for anxiety symptoms can reduce suicidal risk is required in the future. Another important finding of this study is that among the demographic, psychological, and social factors examined, only the experience of being bullied had a moderating effect on the associations between suicidal ideation and attempt and anxiety symptoms in adolescents. Being bullied by peers can result in humiliation and feelings of disgrace, and shatter a youngster’s healthy sense of narcissism and sense of identity (Pfeffer, 1990), and thus it is not surprising that being repeatedly bullied by peers at school can increase the risk of suicidality for the victim (Kim & Leventhal, 2008). Meanwhile, a meta-analysis of longitudinal studies revealed a significant association between peer victimization and subsequent increased anxiety, as well as a significant association between anxiety and subsequent occurrence of peer victimization (Reijntjes, Kamphuis, Prinzie et al., 2010). This study found that the association between suicidal ideation and anxiety symptoms was more significant in adolescents who had no experience of being bullied than in adolescents who had the experience of being bullied. One of possible explanations for the result is that bullying victimization may increase the risks of multiple mental health problems, such as depression, substance use, and low self-esteem (Spivak & Prothrow-Stith, 2001), which all increase the risk of suicidality and reduce the association between anxiety and suicidality. Although the association between anxiety symptoms and suicidal ideation was different between the adolescents with and without the experience of bullying victimization, anxiety symptoms still need to be screened and intervention performed in adolescent victims because of the negative impacts that anxiety symptoms may

112

result in. Further study is needed to examine what kinds of factors may influence the association between anxiety and suicidality among adolescents with the experience of bullying victimization. This study found that gender and age had no moderating effects on the association between anxiety symptoms and suicidality. This result was contrary to our hypothesis. For example, several previous studies have found that female (Goldacre & Hawton, 1985; Tang, Ko, Yen et al., 2009; Wang, Lai, Hsu et al., 2011) and older adolescents (Foley, Goldston, Costello et al., 2006) were more likely to have suicidal ideation and attempt than male and younger ones, respectively. It is thus reasonable to hypothesize that female and older adolescents with anxiety symptoms have a higher risk of suicidal ideation and attempt than male and younger ones with anxiety symptoms, respectively. A previous study reported that an association between suicidality and anxiety was found in male but not in female adolescents (McMahon, Reulbach, Corcoran et al., 2010). However, the result of this study did not support the moderating effects of gender and age. This study found that low self-esteem and low family function were significantly associated with adolescent suicidal ideation and attempt, which was in line with the results of previous studies (Tang, Ko, Yen et al., 2009). However, neither self-esteem nor family function had a moderating effect on the association between suicidality and anxiety symptoms. Research has determined that comorbid substance use disorder (SUD) and comorbid anxiety disorder may index a different pattern of risk factors for adolescent suicidality than pure SUD and pure anxiety disorder. For example, irritability due to generalized anxiety disorder (GAD) and SUD-related recklessness plus hopelessness may jointly increase the risk of suicidality more than either individual feature does without the other (Foley, Goldston, Costello et al., 2006). Meanwhile, comorbid SUD and



C.–F. Yen et al.

comorbid GAD also may increase psychic pain such as social disengagement or loneliness, or contextual factors such as negative life events or family dysfunction, which all increase the risk of suicidality in adolescents (Foley, Goldston, Costello et al., 2006). However, the association between suicidality and anxiety symptoms was not significantly different between adolescents with and without problematic alcohol use in this study. Only the moderating effect of problematic alcohol use was examined in this study. Research has found that adolescents using illicit drugs such as methamphetamine were more likely to have a suicidal tendency than those who do not use illicit drugs (Yen & Shieh, 2005). Further study is needed to examine the moderating effect of illicit drug use on the association between suicidality and anxiety symptoms in adolescents. Research has found that depression is a major psychiatric risk factor for suicidality in adolescents (Foley, Goldston, Costello et al., 2006). Meanwhile, depressive disorders and anxiety disorders are highly comorbid (Kessler, McGonagle, Zhao et al., 1994). Thus, the role of depression in the association between anxiety and suicidality is worthy of study. However, the results of previous studies on the moderating effect of depression on the association between suicidality and anxiety were mixed. A previous study found that depression plus GAD was a strong predictor of suicidality in youths (Foley, Goldston, Costello et al., 2006), whereas another study found that patients with major depressive disorder (MDD) who did not attempt suicide had greater anxiety than those with MDD who attempted suicide (Placidi, Oquendo, Malone et al., 2000). To the best of our knowledge, this study is the first one to examine the moderating effect of severe depressive symptoms on the association between anxiety symptoms and suicidality by applying the standard criteria, and this study found that the association between suicidality and anxiety symptoms did not differ significantly between adolescents with

and without comorbid significant depressive symptoms. There are several issues that need to be addressed regarding this result. First, in this study we considered anxiety symptoms as a continuous measure but not a specific diagnosis of anxiety disorders. Further study is needed to examine whether depressive symptoms have different moderating effects on the association between suicidality and different kinds of anxiety disorders. Second, this study measured depressive symptoms but not the diagnosis of mood disorders. Depressive symptoms can occur in depressive disorders, bipolar disorders, and subthreshold depressive syndromes. Research has found that anxiety disorders increase the risk of suicidality in children and adolescents with bipolar disorder (Halfon, Labelle, Cohen et al., 2013). Further study is needed to examine whether the moderating effects of depressive symptoms on the anxiety and suicidality are different among adolescents with different diagnoses of mood disorders. Third, most of previous studies on the relation among depression, anxiety and suicidality were conducted in adult population. Additional survey data are neededed to determine whether the moderating effects of depressive symptoms on the anxiety and suicidality are different among the individuals of different age. Although the moderating effect of severe depressive symptoms on the association between suicidality and anxiety symptoms was not supported in this study, severe depressive symptoms were one of the most significant correlates of suicidal ideation and attempt among adolescents in this study. Severe depressive symptoms should be routinely screened and interventions made in community samples of adolescents. Meanwhile, a previous study found a mediating effect of depression on the association between anxiety and suicidality in male but not in female potential high school dropouts (Thompson, Mazza, Herting et al., 2005). The mediating effect of depression also needs further study.


113



Some limitations of this study should be addressed. First, the cross-sectional research design of this study limited our ability to draw conclusions regarding the causal relationships between anxiety symptoms and suicidal ideation and attempt. Second, although this study identified being bullied as a moderator of the association between anxiety symptoms and suicidal ideation, further study is needed to determine how the moderating effect develops. Third, this study evaluated anxiety symptoms, suicidality, demographic, psychological, and social factors based on adolescents’ selfreports, and no information was collected from adolescents’ parents and teachers. CONCLUSIONS

The results of this study suggested that anxiety symptoms are an independent correlate of suicidal ideation and attempt. Assessment of suicidal ideation and attempt should be routine practice among adolescents who present with anxiety symptoms. In addition, clinicians may use anxiety symptoms for the screening examination when evaluating suicidal ideation and attempt among adolescents in the community. Further study is needed to examine the clinical use of the MASC-T for screening adolescents with suicidal risk. Meanwhile, further prospective study is needed to examine the predicting effect of anxiety symptoms on the occurrence of suicidality. The experience of being bullied had a moderating effect on the associations between suicidal ideation and attempt and anxiety symptoms in adolescents. The results indicated the necessity of further study to examine how the moderating effect of being bullied develops.

Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. Chien-Yu Lai, School of Nursing, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan. Chih-Hung Ko, Department of Psychiatry, Faculty of Medicine, and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. Tai-Ling Liu, Department of Psychiatry, Kaohsiung Medical University Hospital Kaohsiung, Taiwan. Tze-Chun Tang, Department of Psychiatry, Faculty of Medicine, and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. Yu-Yu Wu, YuNing Psychiatric Clinic, Taiwan. Pinchen Yang, Department of Psychiatry, Faculty of Medicine, and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. Dr. CF Yen and Dr. CY Lai contributed equally to this study. Correspondence concerning this article should be addressed to Pinchen Yang, Department of Psychiatry, Kaohsiung Medical University Hospital, No.100, Tzyou 1st Road, Kaohsiung 807, Taiwan. E-mail: [email protected] FUNDING

This project was supported by the grant NSC 98-2410-H-037-005-MY3 awarded by the National Science Council, Taiwan (ROC) and grant KMUH 100-0R48 awarded by Kaohsiung Medical University Hospital. REFERENCES

AUTHOR NOTE

Cheng-Fang Yen, Department of Psychiatry, and Faculty of Medicine, and Graduate Institute of Medicine, College of

114

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, Fourth Edition. American Psychiatric Association, Washington DC.



C.–F. Yen et al.

Baron, R. M., & Kenny, D. A. (1986). The moderatormediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173–1182. Chau, T. T., Hsiao, T. M., Huang, C. T., & Liu, H.W. (1991). A preliminary study of family APGAR index in the Chinese. The Kaohsiung Journal of Medical Sciences, 7, 27–31. Chien, C. P., & Cheng, T. A. (1985). Depression in Taiwan: Epidemiological survey utilizing MC-CES-D. Psychiatria et Neurologia Japonica, 87, 335–338. Costello, E. J., Angold, A., Burns, B. J., Stangl, D. K., Tweed, D. L., Erkanli, A., & Worthman, C. M. (1996). The Great Smoky Mountains Study of youth: Goals, design, methods, and the prevalence of DSM-III-R disorders. Archives of General Psychiatry, 53, 1129–1136. Department of Education, Executive Yuan, Taiwan. (2012). http://www.edu.tw/userfiles/url/2013010 9145427/10109%e6%95%99%e8%82%b2%e6% 96%bd%e6%94%bf%e7%90%86%e5%bf%b5% e8%88%87%e6%94%bf%e7%ad%96_%e4%b8 %8a%e7%b6%b2%e7%89%88.pdf Department of Health, Executive Yuan, Taiwan. (2011). http://www.edu.tw/files/site_content/EDU01/10103 Department of Health, Executive Yuan, Taiwan. (2011). Taiwan area main causes of death, 2009. Retrieved June 30, 2011, from http://www. doh. gov.tw/ CHT2006/ DisplayStatisticFile.aspx?d= 71700&s=1 Foley, D. L., Goldston, D. B., Costello, E. J., & Angold, A. (2006). Proximal psychiatric risk factors for suicidality in youth: The Great Smoky Mountains study. Archives of General Psychiatry, 63, 1017–1024. Giner, L., Carballo, J. J., Guija, J. A., Sperling, D., Oquendo, M. A., Garcia-Parajua, P., & Giner, J. (2007). Psychological autopsy studies: the role of alcohol use in adolescent and young adult suicides. International Journal of Adolescent Medicine Health, 19, 99–113. Goldacre, M., & Hawton, K. (1985). Repetition of self-poisoning and subsequent death in adolescents who take overdoses. The British Journal of Psychiatry, 146, 395–398. Goldston, D. B., Daniel, S. S., Reboussin, D. M., Reboussin, B. A., Frazier, P. H., & Kelley, A. E. (1999). Suicide attempts among formerly hospitalized adolescents: A prospective naturalistic study of risk during the first 5 years after discharge. Journal of American Academy of Child Adolescent Psychiatry, 38, 660–671.

Gould, M. S., King, R., Greenwald, S., Fisher, P., Schwab-Stone, M., Flisher, A. J. ... , & Shaffer, D. (1998). Psychopathology associated with suicidal ideation and attempts among children and adolescents. Journal of American Academy of Child and Adolescent Psychiatry, 37, 915–923. Halfon, N., Labelle, R., Cohen, D., Guilé, J. M., & Breton, J. J. (2013). Juvenile bipolar disorder and suicidality: A review of the last 10 years of literature. European Child and Adolescent Psychiatry, 22, 139–151. Hill, R. M., Castellanos, D., & Pettit, J. W. (2011). Suicide-related behaviors and anxiety in children and adolescents: A review. Clinical Psychology Review, 31, 1133–1144. Kerr, D. C., Preuss, L. J., & King, C. A. (2006). Suicidal adolescents’ social support from family and peers: gender-specific associations with psychopathology. Journal of Abnormal Child Psychology, 34, 103–114. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8–19. Kim, Y. S., Koh, Y. J., & Noh, J. (2001). Development of Korean-Peer Nomination Inventory (K-PNI): An inventory to evaluate school bullying. Journal of Korean Neuropsychiatric Association, 40, 867–875. Kim, Y. S., & Leventhal, B. (2008). Bullying and suicide: A review. International Journal of Adolescent Medicine and Health, 20, 133–154. Klimes-Dougan, B., Free, K., Ronsaville, D., Stillwell, J., Welsh, C. J., & Radke-Yarrow, M. (1999). Suicidal ideation and attempts: A longitudinal investigation of children of depressed and well mothers. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 651–659. Knight, J. R., Sherritt, L., Harris, S. K., Gates, E. C., & Chang, G. (2003). Validity of brief alcohol screening tests among adolescents: A comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcoholism: Clinical and Experimental Research, 27, 67–73. Ko, C. H., Yen, J. Y., Yen, C. F., Chen, C. S., Weng, C. C., & Chen, C. C. (2008). The association between Internet addiction and problematic alcohol use in adolescents: the problem behavior model. Cyberpsychology & Behavior, 11, 571–576. Lerner, R. M., & Castellino, D. R. (2002). Contemporary developmental theory and adolescence: Developmental systems and applied developmental science. The Journal of Adolescent Health, 31, 122–135.


115



March, J. S., Parker, J. D., Sullivan, K., Stallings, P., & Conners, C. (1997). The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 554–565. Mattison, R. E. (1988). Suicide and other consequences of childhood and adolescent anxiety disorders. The Journal of Clinical Psychiatry, 49, 9–11. McMahon, E. M., Reulbach, U., Corcoran, P., Keeley, H. S., Perry, I. J., & Arensman, E. (2010). Factors associated with deliberate self-harm among Irish adolescents. Psychological Medicine, 40, 1811–1819. Ministry of the Interior. (2002). 2001 Taiwan-Fukien demographic fact book: Republic of China. Executive Yuan, Taipei, Taiwan (in Chinese). Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiology Reviews, 30, 133–154. Noyes, R. (1991). Suicide and panic disorder: A review. Journal of Affective Disorder, 22, 1–11. Pfeffer, C. R. (1990). Manifestation of risk factors. In: MacLean, G. (Eds.), Suicide in children and adolescents. pp. 65–88. Toronto: Hogrefe & Huber, Pilowsky, D. J., Wu, L., & Anthony, J. C. (1999). Panic attacks and suicide attempts in mid-adolescence. The American Journal of Psychiatry, 156, 1545–1549. Placidi, G. P., Oquendo, M. A., Malone, K. M., Bordsky, B., Ellis, S. P., & Mann, J. J. (2000). Anxiety in major depression: relationship to suicide attempts. The American Journal of Psychiatry, 157, 1614–1618. Puig-Antich, J., & Chambers, W. (1978). The Schedule for Affective Disorders and Schizophrenia for School Age Children (Kiddie-SADS). New York, NY: New York State Psychiatric Institute. Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. Reijntjes, A., Kamphuis, J. H., Prinzie, P., & Telch, M. J. (2010). Peer victimization and internalizing problems in children: A meta-analysis of longitudinal studies. Child Abuse & Neglect, 34, 244–252. Rosenberg, M. (1965). Society and the adolescent self-image. NJ: Princeton University Press. Smilkstein, G. (1978). The family APGAR: A proposal for a family function test and its use by physicians. The Journal of Family Practice, 6, 1231–1239. Spirito, A. (2002). Understanding attempted suicide in adolescence. In: Spirito, A., and Overholser, J. (Eds.), Evaluating and treating adolescent suicide

116

attempters: From research to practice. CA: Academic Press, pp. 1–17. Spivak, H., & Prothrow-Stith, D. (2001). The need to address bullying—an important component of violence prevention. JAMA, 285, 2131–2132. Tang, T. C., Ko, C. H., Yen, J. Y., Lin, H. C., Liu, S. C., Huang, C. F., & Yen, C. F. (2009). Suicide and its association with individual, family, peer and school factors in a population of 10,233 adolescents in southern Taiwan. Suicide & Life Threatening Behavior, 39, 91–102. Thompson, E. A., Mazza, J. J., Herting, J. R., Randell, B. P., & Eggert, L. L (2005). The mediating roles of anxiety, depression, and hopelessness on adolescent suicidal behaviors. Suicide & Life Threatening Behavior, 35, 14–34. Wang, R. H., Lai, H. J., Hsu, H. Y., & Hsu, M. T. (2011). Risk and protective factors for suicidal ideation among Taiwanese adolescents. Nursing Research, 60, 413–421. Wilburn, V. R., & Smith, D. E. (2005). Stress, selfesteem, and suicidal ideation in late adolescents. Adolescence, 40, 33–45. Yen, C. F., Hsiao, R. C., Ko, C. H., & Yen, J. Y. (2010c). The relationship between overweight/ obesity and self-esteem in adolescents: The moderating effects of socio-demographic characteristics, family support, academic achievement and peer interaction. Taiwanese Journal of Psychiatry [Taipei], 24, 210–221. Yen, C. F., Kim, Y. S., Tang, T. C., Wu, Y. Y., & Cheng, C. P. (2012) Factor structure, reliability, and validity of the Chinese version of the School Bullying Experience Questionnaire. The Kaohsiung Journal of Medical Sciences, 28, 500–505. Yen, C. F., Ko, C. H., Wu, Y. Y., Yen, J. F., Hsu, F. C., & Yang, P. (2010a). Normative data on anxiety symptoms on the Multidimensional Anxiety Scale for Children in Taiwanese children and adolescents: differences in sex, age, and residence and comparison with an American sample. Child Psychiatry and Human Development, 41, 614–623. Yen, C. F., & Shieh, B. L. (2005). Suicidal ideation and correlates in adolescent methamphetamine users. The Journal of Nervous and Mental Disease, 193, 444–449. Yen, C. F., Yang, P., Wu, Y. Y., Hsu, F. C., & Cheng, C. P. (2010b). Factor structure, reliability and validity of the Taiwanese version of the Multidimensional Anxiety Scale for Children. Child Psychiatry and Human Development, 41, 342–352.


Social-Cognitive Moderators of the Relationship between Peer Victimization and Suicidal Ideation among Psychiatrically Hospitalized Adolescents.

Association between suicidal ideation and behavior, and depression, anxiety, and perceived social support in cancer patients.

Relationship between current sleep duration and past suicidal ideation or attempt among Korean adolescents.

Self-esteem and social support as moderators of depression, body image, and disordered eating for suicidal ideation in adolescents.

Depression, suicidal ideation, and suicidal attempt presenting to the emergency department: differences between these cohorts.

Associations between Korean Adolescents' Sexual Orientation and Suicidal Ideation, Plans, Attempts, and Medically Serious Attempts.

Associations between sleep disturbance and suicidal ideation in adolescents admitted to an inpatient psychiatric unit.

Social anxiety symptoms and suicidal ideation in a clinical sample of early adolescents: examining loneliness and social support as longitudinal mediators.

Factors Associated with Suicidal Ideation and Suicide Attempt among School-Going Urban Adolescents in Peru.

Associations between body weight and depression, social phobia, insomnia, and self-esteem among Taiwanese adolescents.

or anxiety disorders.

The Association between Inappropriate Weight Control Behaviors and Suicide Ideation and Attempt among Korean Adolescents.

Associations between depression and anxiety symptoms and retinal vessel caliber in adolescents and young adults.

Examining the unique relations between anxiety sensitivity factors and suicidal ideation and past suicide attempts.

Suicidal ideation in depressed postpartum women: Associations with childhood trauma, sleep disturbance and anxiety.

Oxytocin and Social Sensitivity: Gene Polymorphisms in Relation to Depressive Symptoms and Suicidal Ideation.

AIDS in post-conflict Northern Uganda.

Associations between problematic internet use and adolescents' physical and psychological symptoms: possible role of sleep quality.

Family environment as a moderator of the association between anxiety and suicidal ideation.

The relationship between suicidal ideation and symptoms of depression in Japanese workers: a cross-sectional study.

Depressive symptoms and suicidal ideation in adolescents accompanying a parent in recyclable trash collection.

Associations between cyberbullying and school bullying victimization and suicidal ideation, plans and attempts among Canadian schoolchildren.

Suicidal ideation, mental health problems, and social function in adolescents with eczema: a population-based study.

Active and passive problem solving: moderating role in the relation between depressive symptoms and future suicidal ideation varies by suicide attempt history.