Stress exposure in at-risk, depressed, and suicidal adolescents.

BACKGROUND: Stress exposure contributes to the onset, maintenance, and recurrence of major depressive disorder (MDD) in adolescents. However, the precise stress facets (e.g. chronicity, domain) most strongly linked to outcomes at different stages along the depression severity continuum remain unclear. Across two studies, chronic and episodic stressors were comprehensively assessed among: (a) healthy youth with (High-Risk [HR]) and without (Low-Risk [LR]) a maternal history of MDD and (b) adolescents with current MDD and suicide ideation and healthy controls (HC). METHOD: Study 1 included LR (n = 65) and HR (n = 22) 12- to 14-year-olds (49 females; 56.32%) with no lifetime history of mental disorders. Study 2 enrolled 87 mid-to-late adolescents (64 females; 73.56%), including 57 MDD youth from a short-term intensive treatment service and 30 HCs from the community. All depressed youth reported recent suicide ideation; some had no lifetime history suicide attempts (SI; n = 31) and others reported at least one past year attempt (SA; n = 26). The Life Events and Difficulties Schedule was used to capture stressor severity in both studies. RESULTS: We used multiple linear regression models that adjusted for demographic and clinical covariates. Being in the HR versus LR group was associated with more severe chronic (ß = .22, CI95 = 0.01-0.42, p = .041), independent (ß = .34, CI95 = 0.12-0.56, p = .003), and interpersonal (ß = .23, CI95 = 0.004-0.45, p = .047) stress severity. By contrast, the MDD group reported significantly more severe chronic (ß = .62, CI95 = 0.45-0.79, p < .001) and dependent (ß = .41, CI95 = 0.21-0.61, p < .001) stress than the HC group, but not independent (p = .083) stress. Stress severity did not differ between recent attempters versus youth who reported suicide ideation alone (SA vs. SI contrast). However, the SA group reported a higher rate of targeted rejection events (RR = 3.53, CI95 = 1.17-10.70, p = .026). CONCLUSIONS: Our findings clarify the stressor features that may most strongly contribute to adolescent depression and its clinical correlates at two important points along depression's clinical course.

Predicting the trajectory of non-suicidal self-injury among adolescents.

BACKGROUND: Non-suicidal self-injury (NSSI) is common among adolescents receiving inpatient psychiatric treatment and the months post-discharge is a high-risk period for self-injurious behavior. Thus, identifying predictors that shape the course of post-discharge NSSI may provide insights into ways to improve clinical outcomes. Accordingly, we used machine learning to identify the strongest predictors of NSSI trajectories drawn from a comprehensive clinical assessment. METHODS: The study included adolescents (N = 612; females n = 435; 71.1%) aged 13-19-years-old (M = 15.6, SD = 1.4) undergoing inpatient treatment. Youth were administered clinical interviews and symptom questionnaires at intake (baseline) and before termination. NSSI frequency was assessed at 1-, 3-, and 6-month follow-ups. Latent class growth analyses were used to group adolescents based on their pattern of NSSI across follow-ups. RESULTS: Three classes were identified: Low Stable (n = 83), Moderate Fluctuating (n = 260), and High Persistent (n = 269). Important predictors of the High Persistent class in our regularized regression models (LASSO) included baseline psychiatric symptoms and comorbidity, past-week suicidal ideation (SI) severity, lifetime average and worst-point SI intensity, and NSSI in the past 30 days (bs = 0.75-2.33). Only worst-point lifetime suicide ideation intensity was identified as a predictor of the Low Stable class (b = -8.82); no predictors of the Moderate Fluctuating class emerged. CONCLUSIONS: This study found a set of intake clinical variables that indicate which adolescents may experience persistent NSSI post-discharge. Accordingly, this may help identify youth that may benefit from additional monitoring and support post-hospitalization.

Detecting adolescent depression through passive monitoring of linguistic markers in smartphone communication.

BACKGROUND: Cross sectional studies have identified linguistic correlates of major depressive disorder (MDD) in smartphone communication. However, it is unclear whether monitoring these linguistic characteristics can detect when an individual is experiencing MDD, which would facilitate timely intervention. METHODS: Approximately 1.2 million messages typed into smartphone social communication apps (e.g. texting, social media) were passively collected from 90 adolescents with a range of depression severity over a 12-month period. Sentiment (i.e. positive vs. negative valence of text), proportions of first-person singular pronouns (e.g. 'I'), and proportions of absolutist words (e.g. 'all') were computed for each message and converted to weekly aggregates temporally aligned with weekly MDD statuses obtained from retrospective interviews. Idiographic, multilevel logistic regression models tested whether within-person deviations in these linguistic features were associated with the probability of concurrently meeting threshold for MDD. RESULTS: Using more first-person singular pronouns in smartphone communication relative to one's own average was associated with higher odds of meeting threshold for MDD in the concurrent week (OR = 1.29; p = .007). Sentiment (OR = 1.07; p = .54) and use of absolutist words (OR = 0.99; p = .90) were not related to weekly MDD. CONCLUSIONS: Passively monitoring use of first-person singular pronouns in adolescents' smartphone communication may help detect MDD, providing novel opportunities for early intervention.

Self-referential processing in anorexia nervosa.

OBJECTIVE: Anorexia nervosa (AN) is a serious psychiatric illness associated with significant medical and psychiatric comorbidity and impairment. Theoretical models of AN and self-report studies suggest that negative self-evaluation (i.e., low self-esteem) is related to the development and maintenance of AN. The goal of this study was to extend findings from self-report methodology using a neurocognitive task that probes self-evaluation implicitly and explicitly. METHOD: We compared female adolescent and adult patients with AN (n = 35) and healthy controls (HC, n = 38) on explicit (i.e., endorsement of words as self-relevant), implicit (recall, recognition, reaction time), and composite (i.e., valence index, bias score, drift rates) indices of self-evaluation. We applied a drift-diffusion model to compute the drift rates, reflecting participants' decision-making process as to whether words were self-relevant. The association between self-evaluation indices and eating disorder severity was examined. RESULTS: There were significant Group × Condition interaction effects for all explicit and implicit measures (all p's ≤ .01), where the AN group endorsed, recalled, and recognized more negative relative to positive words than HC. The AN group had more negative valence index and bias scores, and slower drift rate away from negative words, reflecting more negative self-evaluation. The finding for recall was attenuated when individuals with depression were excluded. Measures of self-evaluation bias were not related to eating disorder severity. DISCUSSION: Using a neurocognitive approach that includes explicit and implicit indices of bias, results suggest that patients with AN have more negative self-evaluation. Due to the cross-sectional design, additional studies are needed to further evaluate directionality. PUBLIC SIGNIFICANCE: Negative self-evaluation/low self-esteem is thought to contribute to eating disorder symptoms. Findings of this study using a neurocognitive task to probe self-evaluation suggested that individuals with anorexia nervosa have more negative self-evaluation, reflected by endorsing and remembering more negative (than positive) words compared to healthy controls, and doing so faster. Targeting the construct of negative self-evaluation in treatment of AN may be warranted.

Editorial: Why Are Children Hurting Themselves and What Can We Do?

Alarmingly, suicide is now a leading cause of death for preadolescent youth (ie, less than 13 years of age), and among community samples, 2.56% report lifetime suicide attempts with 15.08% experiencing suicidal ideation.1 Predictable but preventable factors have conspired to propel us toward this public health crisis. Chief among them is that approximately 45% of individuals in the United States reside in communities with shortages of mental health professionals,2 a problem that is disproportionately affecting youth of color. The reduced access to psychiatric care means that treatment for many preadolescent youth, particularly during non-acute periods when many interventions are most effective, is delayed given limited clinician availability. Furthermore, the increased acuity of the modal case may be contributing to clinician burnout, further diminishing an already beleaguered workforce. Moreover, societal cracks present prior to the COVID-19 pandemic were further exacerbated, including increased loneliness and isolation3 as well as educational inequities,4 which have led to more pronounced social disconnectedness and greater stress exposure (eg, academic challenges)-factors directly implicated in suicidal thoughts and behaviors (STB).5 Although substantial efforts are underway to improve the short-term prediction of adolescent and adult STB, limited research has focused on clarifying which preadolescent youth are at risk and when that risk is greatest.

Neural sensitivity following stress predicts anhedonia symptoms: a 2-year multi-wave, longitudinal study.

Animal models of depression show that acute stress negatively impacts functioning in neural regions sensitive to reward and punishment, often manifesting as anhedonic behaviors. However, few human studies have probed stress-induced neural activation changes in relation to anhedonia, which is critical for clarifying risk for affective disorders. Participants (N = 85, 12-14 years-old, 53 female), oversampled for risk of depression, were administered clinical assessments and completed an fMRI guessing task during a baseline (no-stress) period to probe neural response to receipt of rewards and losses. After the initial task run of the fMRI guessing task, participants received an acute stressor and then, were re-administered the guessing task. Including baseline, participants provided up to 10 self-report assessments of life stress and symptoms over a 2 year period. Linear mixed-effects models estimated whether change in neural activation (post- vs. pre-acute stressor) moderated the longitudinal associations between life stress and symptoms. Primary analyses indicated that adolescents with stress-related reductions in right ventral striatum response to rewards exhibited stronger longitudinal associations between life stress and anhedonia severity (ß = -0.06, 95%CI[-0.11, -0.02], p = 0.008, pFDR = 0.048). Secondary analyses showed that longitudinal positive associations between life stress and depression severity were moderated by stress-related increases in dorsal striatum response to rewards (left caudate ß = 0.11, 95%CI[0.07,0.17], p < 0.001, pFDR = 0.002; right caudate ß = 0.07, 95%CI[0.02,0.12], p = 0.002, pFDR = 0.003; left putamen ß = 0.09, 95%CI[0.04, 0.14], p < 0.001, pFDR = 0.002; right putamen ß = 0.08, 95%CI[0.03, 0.12], p < 0.001, pFDR = 0.002). Additionally, longitudinal positive associations among life stress and anxiety severity were moderated by stress-related reductions in dorsal anterior cingulate cortex (ß = -0.07, 95%CI[-0.12,.02], p = 0.008, pFDR = 0.012) and right anterior insula (ß = -0.07, 95%CI[-0.12,-0.02], p = 0.002, pFDR = 0.006) response to loss. All results held when adjusting for comorbid symptoms. Results show convergence with animal models, highlighting mechanisms that may facilitate stress-induced anhedonia as well as a separable pathway for the emergence of depressive and anxiety symptoms.

Why do adolescents attempt suicide? Insights from leading ideation-to-action suicide theories: a systematic review.

Suicide is a leading cause of death among adolescents, and recent suicide theories have sought to clarify the factors that facilitate the transition from suicide ideation to action. Specifically, the Interpersonal Theory of Suicide (IPTS), Integrated Motivational-Volitional Model (IMV), and Three Step Theory (3ST) have highlighted risk factors central to the formation of suicidal ideation and suicidal behaviors, which is necessary for suicide death. However, these models were initially developed and tested among adults, and given core socioemotional and neurodevelopmental differences in adolescents, the applicability of these models remains unclear. Directly addressing this gap in knowledge, this systematic review aimed to (1) describe the evidence of leading ideation-to-action theories (i.e., IPTS, IMV, 3ST) as they relate to suicide risk among adolescents, (2) integrate ideation-to-action theories within prevailing biological frameworks of adolescent suicide, and (3) provide recommendations for future adolescent suicide research. Overall, few studies provided a complete test of models in adolescent samples, and empirical research testing components of these theories provided mixed support. Future research would benefit from integrating neurodevelopmental and developmentally sensitive psychosocial frameworks to increase the applicability of ideation-to-action theories to adolescents. Further, utilizing real-time monitoring approaches may serve to further clarify the temporal association among risk factors and suicide.

Suicidal ideation risk among LGB Spanish university students: The role of childhood and adolescence adversities and mental disorders.

BACKGROUND: Childhood/adolescence adversities and mental disorders are higher among LGB youths. AIMS: To evaluate the role of childhood maltreatment, bullying, and mental disorders on the association between sexual orientation and suicidal ideation (SI); and the role of mental disorders on the association between sexual orientation discrimination and SI. METHODS: Baseline and 12-month follow-up online surveys of Spanish first-year university students (18-24-year-olds). Multivariable logistic regression models assessed the effects of childhood/adolescence adversities and mental disorders in the relationship between sexual orientation, discrimination and SI. RESULTS: A total of 1224 students were included (16.4 % LGBs). Risk factors of lifetime SI were sexual orientation (OR 2.4), any bullying (OR 2.4), any childhood maltreatment (OR 4.0), and any mental disorders (OR 3.8). Final model Area Under the Curve (AUC) 0.78. Among homosexual and bisexual students, discrimination showed increased risk of 12-month SI (OR 2.2), but this effect was no longer statistically significant when any 12-month mental disorder was added (OR 7.8). Final model AUC 0.72. LIMITATIONS: Sample of interest was relatively small. But it was similar to comparable studies and statistical adjustments have been performed. Assessment of mental disorders and SI was not based on clinical assessment. However, validated scales showing good diagnostic agreement with clinical judgement were used. CONCLUSIONS: Childhood/adolescence adversities and mental disorders interact in the association between sexual orientation and SI. Mental disorders may mediate the association between sexual orientation discrimination and SI. Further research using larger samples and causal modelling approach assessing the mediators of SI risk among LGBs is needed.

The effects of family support and smartphone-derived homestay on daily mood and depression among sexual and gender minority adolescents.

Sexual and gender minority (SGM) adolescents are at elevated risk for depression. This risk is especially pronounced among adolescents whose home environment is unsupportive or nonaffirming, as these adolescents may face familial rejection due to their identity. Therefore, it is critical to better understand the mechanisms underlying this risk by probing temporally sensitive associations between negative mood and time spent in potentially hostile home environments. The current study included adolescents (N = 141; 43% SGM; 13-18 years old), oversampled for depression history, who completed clinical interviews assessing lifetime psychiatric history and depression severity as well as self-report measures of social support. Participants also installed an app on their personal smartphones, which assessed their daily mood and geolocation-determined mobility patterns over a 6-month follow-up period. Over the 6-month follow-up period, SGM adolescents reported elevated depression severity and lower daily mood relative to non-SGM youth. Interestingly, SGM adolescents who reported low family support experienced lower daily mood than non-SGM adolescents, particularly on days when they spent more time at home. Current findings reinforce evidence for disparities in depression severity among SGM adolescents and highlight family support as a key factor. Specifically, more time spent in home environments with low family support was associated with worse mood among SGM adolescents. These results underscore the need for clinical interventions to support SGM youth, particularly interventions that focus on familial relationships and social support within the home environment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Study Preregistration: Testing a Digital Suicide Risk Reduction Platform for Adolescents: A Pragmatic Randomized Controlled Trial.

Suicide is the second leading cause of death among adolescents, and rates of suicidal thoughts and behaviors (STBs) are climbing.1 Promising interventions such as dialectical behavior therapy (DBT) are available to treat suicidal youth, and new approaches may facilitate greater intervention engagement, adherence, and effectiveness.2 Digital tools (eg, personal smartphones) are a particularly promising avenue and could enhance existing, evidence-based interventions by providing new opportunities for assessment and intervention between sessions.

Identifying factors impacting missingness within smartphone-based research: Implications for intensive longitudinal studies of adolescent suicidal thoughts and behaviors.

Intensive longitudinal research-including experience sampling and smartphone sensor monitoring-has potential for identifying proximal risk factors for psychopathology, including suicidal thoughts and behaviors (STB). Yet, missing data can complicate analysis and interpretation. This study aimed to address whether clinical and study design factors are associated with missing data and whether missingness predicts changes in symptom severity or STB. Adolescents ages 13- to 18 years old (N = 179) reporting depressive, anxiety, and/or substance use disorders were enrolled; 65% reported current suicidal ideation and 29% indicated a past-year attempt. Passively acquired smartphone sensor data (e.g., global positioning system, accelerometer, and keyboard inputs), daily mood surveys, and weekly suicidal ideation surveys were collected during the 6-month study period using the effortless assessment research system smartphone app. First, acquisition of passive smartphone sensor data (with data on ∼80% of days across the whole sample) was strongly associated with survey data acquisition on the same day (∼44% of days). Second, STB and psychiatric symptoms were largely not associated with missing data. Rather, temporal features (e.g., length of time in study, weekends, and summer) explained more missingness of survey and passive smartphone sensor data. Last, within-participant changes in missing data over time neither followed nor predicted subsequent change in suicidal ideation and psychiatric symptoms. Findings indicate that considering technical and study design factors impacting missingness is critical and highlight several factors that should be addressed to maximize the validity of clinical interpretations in intensive longitudinal research. (PsycInfo Database Record (c) 2024 APA, all rights reserved).