Chat with us, powered by LiveChat Please choose a health topic that interests you and that you might operate as a health promotional program in the future or as - School Writers

Please choose a health topic that interests you and that you might operate as a health promotional program in the future or as

Instructions:

Please choose a health topic that interests you and that you might operate as a health promotional program in the future or as part of this class. Using the Internet, find sources and review the current literature on this topic. Find 5 sources that are relevant to your topic¾the majority (4 sources) should be from peer-reviewed journals.

Some guiding questions to help your Internet search:

· How significant is this health condition?
 ·  What causes this condition?
 ·  What is this health condition linked to (genetic, behavior, or environment)?
 ·  Who is more affected by this health issue?
 ·  What is currently being done to address this condition nationally, statewide, and locally?
 ·  What health education programs are being done with the health condition topic?
 ·  In what innovative ways are researchers addressing your health issues?

The annotated bibliography should be prepared using APA (American Psychological Association) format and include a brief summary paragraph about each source below its entry, as shown in the examples below.

ONE Health Topics I find interesting: youth suicide and prevention.

Resources:

Preventing Adolescent and Young Adult Suicide: Do States With

Greater Mental Health Treatment Capacity Have Lower Suicide

Rates?

Youth suicide in the school context

Youth Suicide Risk and Preventive Interventions:

A Review of the Past 10 Years

School-Based Suicide Prevention Laws in Action: A Nationwide Investigation of Principals' Knowledge of and Adherence to State School-Based Suicide Prevention Laws

https://www.apa.org/research/action/suicide

Instructions:

Please choose a health topic that interests you and that you might operate as a health promotional program in the future or as part of this class. Using the Internet, find sources and review the current literature on this topic. Find 5 sources that are relevant to your topic¾the majority (4 sources) should be from peer-reviewed journals.

Some guiding questions to help your Internet search:

        ·  How significant is this health condition?         ·  What causes this condition?         ·  What is this health condition linked to (genetic, behavior, or environment)?         ·  Who is more affected by this health issue?         ·  What is currently being done to address this condition nationally, statewide, and locally?         ·  What health education programs are being done with the health condition topic?         ·  In what innovative ways are researchers addressing your health issues?

The annotated bibliography should be prepared using APA (American Psychological Association) format and include a brief summary paragraph about each source below its entry, as shown in the examples below.

Example Annotated Bibliography Entries

Adams, T., Moore, M., & Dye, J. (2007). The relationship between physical activity and mental health in a national sample of college females. Women & Health, 45(1), 69-85. Retrieved from EBSCOhost.

This study analyzed the effects of physical activity on the mental health of college females. 22,073 females participated where depression, anxiety, suicidal ideation, and perceived health were the defendant variables and two bouts of weekly exercise were the independent variables. Exercise was shown to endorse a positive perceived health and alleviate feelings of depression. This article is important because depression and self-esteem in college-aged females is a prevalent issue and needs more attention. This population is sometimes forgotten about and the mental health of these students is very important.

Justine, M., & Hamid, T. (2010). A multicomponent exercise program for institutionalized older adults: effects on depression and quality of life. Journal of Gerontological Nursing, 36(10), 32-41. doi: 10.3928/00989134-20100330-09

This study is different because it used exercise as a treatment for depression in institutionalized older adults. The study took place in a shelter home in Malaysia where 23 volunteers over the age of 60 performed 60 minutes of exercise three times a week for 12 weeks. The control was 20 sedentary older adults. At the end of 12 weeks, the physically active older adults reported an improvement in quality of life. This study is also important to include because it examines the relationship between exercise and depression in a country other than the United States.

See attached rubric.

,

Objectives/Criteria Performance Indicators Needs Improvement

Meets Expectations Exceptional

Quantity of Work (1 point) Less than 5 sources used or 3 or more non-peer- reviewed journals used.

(1.5 points) 5 sources used with 2 non-peer- reviewed sources.

(2 points) At least 5 appropriate sources were used with 4 or fewer non-peer reviewed.

Currency The timeliness of the information.

(1 point) Less than 50% of the sources had currency described.

(1.5 points) Inconsistently answered the following questions about the currency of each source.

(2 points) Able to consistently answer the following questions about the currency of each source: • When was the information

published or posted? • Has the information been revised

or updated? • Is the information current or out-

of-date for the topic? • Is the source URL functional?

Relevance The importance of the information for your needs.

(0-4 point) Less than 50% of the sources had the relevance described.

(5 points) Inconsistently answered the following questions about

(7 points) Able to consistently answer the following questions about the relevance of each source:

the relevance of each source.

• Does the information relate to your topic or answer your question?

• Who is the intended audience? • Is the information at an

appropriate level (i.e., not too elementary or advanced for your needs)?

• Have you looked at a variety of sources before determining this is one you will use?

• Would you consider using this source for a research paper?

Authority The source of the information.

(1 point) Less than 50% of the sources had the authority described.

(1.5 points) Inconsistently answered the following questions about the authority of each source.

(2 points) Able to consistently answer the following questions about the authority of each source: • Who is the author/

publisher/source/sponsor? • Are the author’s credentials or

organizational affiliations given? • What are the author’s

qualifications to write on the topic?

• Is there contact information, such as a publisher or email address?

• Does the source URL reveal anything about the author or source (e.g., .com, .edu, .gov, .org, .net)?

Accuracy The reliability, truthfulness, and correctness of the informational content.

(0-4 points) Less than 50% of the sources had the accuracy described.

(5 points) Inconsistently answered the following questions about the accuracy of each source.

(7 points) Able to consistently answer the following questions about the accuracy of each source: • Where does the information come

from? • Is the information supported by

evidence? • Has the information been

reviewed or refereed? • Can you verify any of the

information in another source or from personal knowledge?

• Does the language or tone seem biased and free of emotion?

• Are there spelling, grammar, or other typographical errors?

Purpose The reason the information exists.

(1 point) Less than 50% of the sources had the purpose described.

(1.5 points) Inconsistently answered the following questions about

(2 points) Able to consistently answer the following questions about the purpose of each source:

the purpose of each source.

• What is the purpose of the information? Inform? Teach? Sell? Entertain? Persuade?

• Do the authors/sponsors make their intentions or purpose clear?

• Is the information fact? Opinion? Propaganda?

• Does the point of view appear objective and impartial?

• Are there political, ideological, cultural, religious, institutional, or personal biases?

Audience Awareness

(1.5 points) Multiple errors: 4+ errors in the APA formatting, personal references were used, and/or issues with grammar, spelling, and format.

(2.5 points) Minor errors: 1–2 errors in the APA formatting, formatting issues, language issues, and/or grammar and spelling problems.

(3 points) Clear understanding of the audience was demonstrated in the annotations. Appropriate language was used, with no personal references (I, we, my). APA style was used and document formatted for easy reading.

Out of 25 points:

,

The research contributing to our understanding of who is at risk for suicide and how to prevent and treat suicide will be critically evaluated. A comprehensive understanding of this information is critical to clinicians who deal with the mental health problems of children and adolescents. Each year, one in five teenagers in the United States seri-

ously considers suicide (Grunbaum et al., 2002); 5% to 8% of adolescents attempt suicide, representing approx- imately 1 million teenagers, of whom nearly 700,000 receive medical attention for their attempt (Grunbaum et al., 2002); and approximately 1,600 teenagers die by suicide (Anderson, 2002). Only by recognizing who is at risk for suicide, and knowing how to prevent suicidal behavior and provide treatment for suicidal individuals, will mental health practitioners and those designing edu- cational and public health prevention programs have suf- ficient armamentaria to combat this major public health and clinical problem in youths. The current review is based on a comprehensive, but not exhaustive, review of the research on youth suicide conducted in the past decade. Preference was given to population-based epidemiolog- ical and longitudinal investigations and controlled pre- vention/intervention studies.

OVERALL RATES AND SECULAR PATTERNS

Suicide was the third leading cause of death among 10- to 14-year-olds and 15- to 19-year-olds in the United

Accepted December 3, 2002. Dr. Gould is a Professor at Columbia University in the Division of Child and

Adolescent Psychiatry (College of Physicians & Surgeons) and Department of Epidemiology (School of Public Health) and a Research Scientist at the New York State Psychiatric Institute (NYSPI). Mr. Greenberg is with the Division of Child and Adolescent Psychiatry, Columbia University, NYSPI. Dr. Velting is an Assistant Professor at Columbia University in the Division of Child and Adolescent Psychiatry (College of Physicians & Surgeons), and Dr. Shaffer is Irving Philips Professor of Child Psychiatry and Pediatrics at the College of Physicians & Surgeons at Columbia University.

The expert assistance of Margaret Lamm in the preparation of this manu- script is gratefully acknowledged.

Reprint requests to Dr. Gould, Division of Child and Adolescent Psychiatry, NYSPI, 1051 Riverside Drive, Unit 72, New York, NY 10032; e-mail: [email protected]

0890-8567/03/4204–0386�2003 by the American Academy of Child and Adolescent Psychiatry.

DOI: 10.1097/01.CHI.0000046821.95464.CF

Youth Suicide Risk and Preventive Interventions: A Review of the Past 10 Years

MADELYN S. GOULD, PH.D., M.P.H., TED GREENBERG, M.P.H., DREW M. VELTING, PH.D., AND DAVID SHAFFER, M.D.

ABSTRACT

Objective: To review critically the past 10 years of research on youth suicide. Method: Research literature on youth suicide

was reviewed following a systematic search of PsycINFO and Medline. The search for school-based suicide prevention pro-

grams was expanded using two education databases: ERIC and Education Full Text. Finally, manual reviews of articles’ ref-

erence lists identified additional studies. The review focuses on epidemiology, risk factors, prevention strategies, and treatment

protocols. Results: There has been a dramatic decrease in the youth suicide rate during the past decade. Although a num-

ber of factors have been posited for the decline, one of the more plausible ones appears to be the increase in antidepres-

sants being prescribed for adolescents during this period. Youth psychiatric disorder, a family history of suicide and

psychopathology, stressful life events, and access to firearms are key risk factors for youth suicide. Exciting new findings have

emerged on the biology of suicide in adults, but, while encouraging, these are yet to be replicated in youths. Promising pre-

vention strategies, including school-based skills training for students, screening for at-risk youths, education of primary care

physicians, media education, and lethal-means restriction, need continuing evaluation studies. Dialectical behavior ther-

apy, cognitive-behavioral therapy, and treatment with antidepressants have been identified as promising treatments but

have not yet been tested in a randomized clinical trial of youth suicide. Conclusions: While tremendous strides have been

made in our understanding of who is at risk for suicide, it is incumbent upon future research efforts to focus on the devel-

opment and evaluation of empirically based suicide prevention and treatment protocols. J. Am. Acad. Child Adolesc.

Psychiatry, 2003, 42(4):386–405. Key Words: suicide, epidemiology, risk factors, prevention, treatment, adolescence.

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States in 2000 (Anderson, 2002). While the rates of com- pleted suicide are low (1.5 per 100,000 among 10- to 14- year-olds and 8.2 per 100,000 among 15- to 19-year-olds), when nonlethal suicidal behavior and ideation are taken into account, the magnitude of the problem becomes obvi- ous. The surge of general population studies of suicide attempts and ideation has yielded reliable estimates of their rates (e.g., Andrews and Lewinsohn, 1992; Fergusson and Lynskey, 1995; Fergusson et al., 2000; Garrison et al., 1993; Gould et al., 1998; Grunbaum et al., 2002; Lewinsohn et al., 1996; Roberts and Chen, 1995; Sourander et al., 2001; Swanson et al., 1992; Wichstrom, 2000; Windle et al., 1992). Of these studies, the largest and the most representative is the Youth Risk Behavior Survey (YRBS) (Grunbaum et al., 2002), conducted by the Centers for Disease Control and Prevention (CDC). The YRBS indicated that during the past year, 19% of high school students “seriously considered attempting suicide,” nearly 15% made a specific plan to attempt suicide, 8.8% reported any suicide attempt, and 2.6% made a medically serious suicide attempt that required medical attention. These results are consistent with those cited in the epi- demiological literature.

Age

Suicide is uncommon in childhood and early adoles- cence. Within the 10- to 14-year-old group, most sui- cides occur between ages 12 and 14. Suicide incidence increases markedly in the late teens and continues to rise until the early twenties, reaching a level that is maintained throughout adulthood until the sixth decade, when the rates increase markedly among men (Anderson, 2002).

In 2000, the suicide mortality rate for 10- to 14-year- olds in the United States was 1.5 per 100,000. Although 10- to 14-year-olds represented 7.2% of the U.S. popu- lation, the 300 children who committed suicide repre- sented only 1.0% of all suicides. The suicide mortality rate for 15- to 19-year-olds was 8.2 per 100,000, five times the rate of the younger age group.

The rarity of completed suicide before puberty is a universal phenomenon (World Health Organization, 2002). Shaffer et al. (1996) suggested that the most likely reason underlying the age of onset of suicide is that depres- sion and exposure to drugs and alcohol, two significant risk factors for suicide in adults (e.g., Barraclough et al., 1974; Robins et al., 1959) and adolescents (e.g., Brent et al., 1993a; Shaffer et al., 1996), are rare in very young children and become prevalent only in later adolescence.

Like completed suicides, suicide attempts are relatively rare among prepubertal children and increase in frequency through adolescence (Andrus et al., 1991; Velez and Cohen, 1988). However, unlike completed suicides, attempts peak between 16 and 18 years of age, after which there is a marked decline in frequency (Kessler et al., 1999), particularly for young women (Lewinsohn et al., 2001).

Gender

Paradoxically, although suicidal ideation and attempts are more common among females (Garrison et al., 1993; Gould et al., 1998; Grunbaum et al., 2002; Lewinsohn et al., 1996) in the United States, completed suicide is more common among males. Five times more 15- to 19- year-old boys than girls commit suicide (Anderson, 2002). The same pattern of sex differences does not exist in all countries (World Health Organization, 2002). While completed suicide is more common in 15- to 24-year old males than females in North America, Western Europe, Australia, and New Zealand, sex rates are equal in some countries in Asia (e.g., Singapore), and in China, the majority of suicides are committed by females.

The YRBS (Grunbaum et al., 2002) indicated that girls were significantly more likely to have seriously con- sidered attempting suicide (23.6%), made a specific plan (17.7%), and attempted suicide (11.2%) than were boys (14.2%, 11.8%, 6.2%, respectively); however, no signif- icant difference by gender in the prevalence of medically serious attempts (3.1% females, 2.1% males) was found.

Both psychopathological factors and sex-related method preferences are considered to contribute to the pattern of sex differences (Shaffer and Hicks, 1994). Completed sui- cide is often associated with aggressive behavior and sub- stance abuse (see discussion below), and both are more common in males. Methods favored by women, such as overdoses, which account for 30% of all female suicides yet only 6.7% of all male suicides (CDC, 2002), tend to be less lethal in the United States. However, in societies where treatment resources are not readily available or when the chosen ingestant is untreatable, overdoses are more likely to be lethal. Whereas in the United States, only 11% of completed suicides in 1999 resulted from an ingestion, in some South Asian and South Pacific coun- tries, the majority of suicides are due to ingestions of her- bicides, such as paraquat, for which no effective treatment is available (Haynes, 1987; Shaffer and Hicks, 1994).

YO U T H S U I C I D E R I S K A N D I N T E RV E N T I O N S

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Ethnicity

Youth suicide is more common among whites than African Americans in the United States (Anderson, 2002), although the rates are highest among Native Americans and generally the lowest among Asian/Pacific Islanders (Anderson, 2002; Shiang et al., 1997; Wallace et al., 1996). Latinos are not overrepresented among completed sui- cides in the United States (Demetriades et al., 1998; Gould et al., 1996; Smith et al., 1985). The historically higher suicide rate among Native Americans is not fully under- stood, but proposed risk factors include low social inte- gration, access to firearms, and alcohol or drug use (Borowsky et al., 1999; Middlebrook et al., 2001). The historically lower suicide rate among African Americans has been attributed to greater religiosity and differences in “outwardly” rather “inwardly” directed aggression (Gibbs, 1997; Shaffer et al., 1994). However, the differ- ence in suicide rates between whites and African Americans has decreased during the past 15 years because of a marked increase in the suicide rate among African-American males between 1986 and 1994.

The YRBS (Grunbaum et al., 2002) found that African- American students were significantly less likely (13.3%) than white or Latino students (19.7% and 19.4%, respec- tively) to have considered suicide or to have made a spe- cific plan (African-Americans: 10.3%; whites: 15.3%; Latinos: 14.1%). Latino students (12.1%) were signifi- cantly more likely than either African-American or white students to have made a suicide attempt (8.8% and 7.9%, respectively); however, there was no preponderance of medically serious attempts among Latinos (3.4%) com- pared with whites (2.3%) or African Americans (3.4%). Although some studies have found higher rates of sui- cidal ideation and attempts among Latino youths (Roberts et al., 1997; Roberts and Chen, 1995), Grunbaum et al. (1998) and Walter et al. (1995) did not find a higher prevalence of either among Latinos. These equivocal find- ings highlight the need for further research in this area.

Secular Trends

Secular changes in the incidence of a disease are impor- tant because they may give an indication of causal and/or preventive factors. Following a nearly threefold increase in the adolescent male suicide rate between 1964 and 1988, the consistent increase in the white male suicide rate ceased and in the mid 1990s started to decline. Rates in African-American males, while still lower than among whites, showed no sign of a plateau or decrease until 1995.

At that time the decline gathered pace and included both white and African-American males and females. The rate among white males, nearly 20/100,000 in 1988, had fallen to approximately 14/100,000 by the year 2000 (Fig. 1).

The reasons for the decline are by no means clear. One of the more plausible reasons for the earlier increase had been the effects of greater exposure of the youth popu- lation to drugs and alcohol. Alcohol use had been noted to be a significant risk factor for suicide since the first psychological autopsy study (Robins et al., 1959), and at least in some studies (Shaffer et al., 1996) it has been a significantly more important risk factor for males, the group that had showed the dramatic increase. However, repeat benchmark studies that use similar measures and sampling methods such as the YRBS (CDC, 1995, 1996, 1998, 2000; Grunbaum et al., 2002) give no indication of a decline in alcohol or cocaine use during this time. Another reason posited for the earlier increase was an increased availability of firearms (Brent et al., 1991). Legislation restricting access to firearms was passed in 1994 (Ludwig and Cook, 2000), at the time that the decrease became more marked and the rate of handling firearms among high school students declined (CDC, 1995, 1996, 1998, 2000; Grunbaum et al., 2002). However, the proportion of suicides by firearms, a plausible proxy for method availability (Cutright and Fernquist, 2000), did not change between 1988 and 1999. There has been a decline ranging from 20% to 30% in the youth suicide rates in England, Finland, Germany, and Sweden, where firearms account for very few suicides (Krug et al., 1998), and a systematic examination of the proportion of sui- cides committed with firearms over a long period of time has shown that the proportion is only weakly related to overall changes in the rate (Cutright and Fernquist, 2000).

Another plausible cause of the reduction has been the extraordinary increase in antidepressants being prescribed for adolescents during this period. Olfson et al. (2002b) showed that between 1987 and 1996 the annual rate of antidepressant use increased from approximately 0.3% to 1.0% of those aged 6 to 19 years in the United States. Selective serotonin reuptake inhibitors (SSRIs) affect not only depression (see “Psychopharmacological Interventions” below), but also aggressive outbursts, and have been shown in adults to reduce suicidal thinking. It is unlikely that the increase in the prescription of antidepressants is an indication of a more general increase in access or use of mental health services. During the period from 1987 to 1997, the number of adolescents who received psycho-

G O U L D E T A L .

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therapy actually declined (Olfson et al., 2002a). The delay in the onset of the decline in African-American suicides is compatible with a treatment effect because of African Americans’ greater difficulty in accessing treatment resources (Goodwin et al., 2001). Another indication that antide- pressant treatment may be a factor in the recent decline is the finding in Sweden that the proportion of suicide victims who received antidepressant treatment is lower than the rest of the depressed population (Isacsson, 2000). Firm conclusions, however, are not possible given the ecological nature of the supporting data. Randomized clinical trials will be necessary before the decline in rates can be confidently attributed to treatment with antide- pressants.

RISK FACTORS

Personal Characteristics

Psychopathology. More than 90% of youth suicides have had at least one major psychiatric disorder, although younger adolescent suicide victims have lower rates of psychopathology, averaging around 60% (Beautrais, 2001; Brent et al., 1999; Groholt et al., 1998; Shaffer et al., 1996). Depressive disorders are consistently the most

prevalent disorders among adolescent suicide victims, ranging from 49% to 64% (Brent et al., 1993a; Marttunen et al., 1991; Shaffer et al., 1996). The increased risk of suicide (odds ratios) for those with an affective disorder ranges from 11 to 27 (Brent et al., 1988, 1993a; Groholt et al., 1998; Shaffer et al., 1996; Shafii et al., 1988). Female victims are more likely than males to have had an affec- tive disorder (Brent et al., 1999; Shaffer et al., 1996). Substance abuse is another significant risk factor, espe- cially among older adolescent male suicide victims (Marttunen et al., 1991; Shaffer et al., 1996). A high prevalence of comorbidity between affective and sub- stance abuse disorder has consistently been found (Brent et al., 1993a; Shaffer et al., 1996). Disruptive dis- orders are also common in male teenage suicide victims (Brent et al., 1993a; Shaffer et al., 1996). Approximately one third of male suicides have had a conduct disorder, often comorbid with a mood, anxiety, or substance abuse disorder. Discrepant results have been reported for bipo- lar disorder: Brent et al. (1988, 1993a) reported relatively high rates, whereas others reported no or few bipolar cases (Apter et al., 1993a; Marttunen et al., 1991; Rich et al., 1990; Runeson, 1989; Shaffer et al., 1994). Despite the generally high risk of suicide among people with schizo-

Fig. 1 Teen suicide rates, 1964–2000: United States, ages 15–19 years. Sources: Anderson, 2002; CDC, 2002; National Center for Health Statistics, 1999. *Crude rates; prior to 1979, African-American data not broken out.

phrenia, schizophrenia accounts for very few of all youth suicides (Brent et al., 1993a; Shaffer et al., 1996).

The psychiatric problems and gender-specific diag- nostic profiles of youth suicide attempters are quite sim- ilar to the profiles of those who complete suicide (e.g., Andrews and Lewinsohn, 1992; Beautrais et al., 1996, 1998; Gould et al., 1998). However, despite the overlap between suicidal attempts and ideation (Andrews and Lewinsohn, 1992; Reinherz et al., 1995) and the signif- icant prediction of future attempts from ideation (Lewin- sohn et al., 1994; McKeown et al., 1998; Reinherz et al., 1995), the diagnostic profiles of attempters and ideators are somewhat distinct (Gould et al., 1998). Substance abuse/dependence is more strongly associated with sui- cide attempts than with ideation (Garrison et al., 1993; Gould et al., 1998; Kandel, 1988). Recent studies have found an association between posttraumatic stress disor- der and suicidal behavior among adolescents (Giaconia et al., 1995; Mazza, 2000; Wunderlich et al., 1998), but in the largest and most representative of the studies (Wunderlich et al., 1998), the association was not main- tained after adjusting for comorbid psychiatric problems. Panic attacks have also been reported to be associated with an increased risk of suicidal behavior in adolescents, even after adjusting for comorbid psychiatric disorders and demographic factors (Gould et al., 1996; Pilowsky et al., 1999). The negative finding by Andrews and Lewinsohn (1992) may be due to a gender specificity of the association: panic attacks may increase suicide risk for girls only (Gould et al., 1996). Inconsistent findings have been reported in the adult literature (Johnson et al., 1990; Warshaw et al., 2000; Weissman et al., 1989)

Prior Suicide Attempts. A history of a prior suicide attempt is one of the strongest predictors of completed suicide, conferring a particularly high risk for boys (30- fold increase) and a less elevated risk for girls (3-fold increase) (Shaffer et al., 1996). Between one quarter to one third of youth suicide victims have made a prior sui- cide attempt (see Groholt et al., 1997). Similarly strong associations between a history of suicidal behavior and future attempts have been reported in general popula- tion surveys and longitudinal studies (Lewinsohn et al.,1994; McKeown et al., 1998; Reinherz et al., 1995; Wichstrom, 2000) and clinical samples (Hulten et al., 2001; Pfeffer et al., 1991), with risk for an attempt increasing between 3 and 17 times for those with prior suicidal behavior.

Cognitive and Personality Factors. Hopelessness has been linked with suicidality (Howard-Pitney et al., 1992;

Marcenko et al., 1999; Overholser et al., 1995; Ruben- stein et al., 1989; Russell and Joyner, 2001; Shaffer et al., 1996); however, it has not consistently proven to be an independent predictor, once depression is taken into account (Cole, 1988; Howard-Pitney et al., 1992; Lewinsohn et al., 1994; Reifman and Windle, 1995; Rotheram-Borus and Trautman, 1988). Poor interpersonal problem-solv- ing ability has also been reported to differentiate suicidal from nonsuicidal youths (Asarnow et al., 1987; Rotheram- Borus et al., 1990), even after adjusting for depression (Rotheram-Borus et al., 1990). Social problem-solving has been found to partially mediate the influence of life stress on suicide, although life stress was a stronger pre- dictor than social problem-solving (Chang, 2002). Aggressive- impulsive behavior has also been linked with an increased risk of suicidal behavior (Apter et al., 1993b; McKeown et al., 1998; Sourander et al., 2001). In a Finnish school study (Sourander et al., 2001), aggressive 8-year-olds were more than twice as likely to think about or attempt sui- cide at age 16.

Sexual Orientation. Recent cross-sectional and longi- tudinal epidemiological studies found a significant two- to sixfold increased risk of nonlethal suicidal behavior for homosexual and bisexual youths (Blake et al., 2001; Faulkner and Cranston, 1998; Garofalo et al., 1998; Remafedi et al., 1998; Russell and Joyner, 2001; see McDaniel et al., 2001, for a recent review). In a study of a nationally represen- tative sample of nearly 12,000 adolescents, those who reported same-sex sexual orientation also exhibited sig- nificantly higher rates of other suicide risk factors (Russell and Joyner, 2001). After adjusting for these risks, th

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