Testing the interpersonal theory of suicide in adolescents: A multi-wave longitudinal study.

BACKGROUND: Suicide is a major public health crisis among youth. Several prominent theories, including the Interpersonal Theory of Suicide (IPTS), aim to characterize the factors leading from suicide ideation to action. These theories are largely based on findings in adults and require testing and elaboration in adolescents. METHODS: Data were examined from high-risk 13-18-year-old adolescents (N = 167) participating in a multi-wave, longitudinal study; 63% of the sample exhibited current suicidal thoughts or recent behaviors (n = 105). The study included a 6-month follow-up period with clinical interviews and self-report measures at each of the four assessments as well as weekly smartphone-based assessments of suicidal thoughts and behaviors. Regression and structural equation models were used to probe hypotheses related to the core tenets of the IPTS. RESULTS: Feelings of perceived burdensomeness were associated with more severe self-reported suicidal ideation (b = 0.58, t(158) = 7.64, p < .001). Similarly, burdensomeness was associated with more frequent ideation based on weekly smartphone ratings (b = 0.11, t(1460) = 3.41, p < .001). Contrary to IPTS hypotheses, neither feelings of thwarted belongingness, nor interactions between burdensomeness and thwarted belongingness were significantly associated with ideation (ps > .05). Only elevated depression severity was associated with greater odds of suicide events (i.e., suicide attempts, psychiatric hospitalizations, and/or emergency department visits for suicide concerns) during the follow-up period (OR = 1.83, t(158) = 2.44, p = .01). No effect of acquired capability was found. CONCLUSIONS: Perceptions of burdensomeness to others reflect a critical risk factor for suicidal ideation among high-risk adolescents. Null findings with other IPTS constructs may suggest a need to adopt more developmentally sensitive models or measures of interpersonal and acquired capability risk factors for youth. Refining methods and theoretical models of suicide risk may help improve the identification of high-risk cases and inform clinical intervention.

Intensive Longitudinal Assessment of Adolescents to Predict Suicidal Thoughts and Behaviors.

OBJECTIVE: Suicide is a leading cause of death among adolescents. However, there are no clinical tools to detect proximal risk for suicide. METHOD: Participants included 13- to 18-year-old adolescents (N = 103) reporting a current depressive, anxiety, and/or substance use disorder who owned a smartphone; 62% reported current suicidal ideation, with 25% indicating a past-year attempt. At baseline, participants were administered clinical interviews to assess lifetime disorders and suicidal thoughts and behaviors (STBs). Self-reports assessing symptoms and suicide risk factors also were obtained. In addition, the Effortless Assessment of Risk States (EARS) app was installed on adolescent smartphones to acquire daily mood and weekly suicidal ideation severity during the 6-month follow-up period. Adolescents completed STB and psychiatric service use interviews at the 1-, 3-, and 6-month follow-up assessments. RESULTS: K-means clustering based on aggregates of weekly suicidal ideation scores resulted in a 3-group solution reflecting high-risk (n = 26), medium-risk (n = 47), and low-risk (n = 30) groups. Of the high-risk group, 58% reported suicidal events (ie, suicide attempts, psychiatric hospitalizations, emergency department visits, ideation severity requiring an intervention) during the 6-month follow-up period. For participants in the high-risk and medium-risk groups (n = 73), mood disturbances in the preceding 7 days predicted clinically significant ideation, with a 1-SD decrease in mood doubling participants' likelihood of reporting clinically significant ideation on a given week. CONCLUSION: Intensive longitudinal assessment through use of personal smartphones offers a feasible method to assess variability in adolescents' emotional experiences and suicide risk. Translating these tools into clinical practice may help to reduce the needless loss of life among adolescents.

The ILHBN: challenges, opportunities, and solutions from harmonizing data under heterogeneous study designs, target populations, and measurement protocols.

The ILHBN is funded by the National Institutes of Health to collaboratively study the interactive dynamics of behavior, health, and the environment using Intensive Longitudinal Data (ILD) to (a) understand and intervene on behavior and health and (b) develop new analytic methods to innovate behavioral theories and interventions. The heterogenous study designs, populations, and measurement protocols adopted by the seven studies within the ILHBN created practical challenges, but also unprecedented opportunities to capitalize on data harmonization to provide comparable views of data from different studies, enhance the quality and utility of expensive and hard-won ILD, and amplify scientific yield. The purpose of this article is to provide a brief report of the challenges, opportunities, and solutions from some of the ILHBN's cross-study data harmonization efforts. We review the process through which harmonization challenges and opportunities motivated the development of tools and collection of metadata within the ILHBN. A variety of strategies have been adopted within the ILHBN to facilitate harmonization of ecological momentary assessment, location, accelerometer, and participant engagement data while preserving theory-driven heterogeneity and data privacy considerations. Several tools have been developed by the ILHBN to resolve challenges in integrating ILD across multiple data streams and time scales both within and across studies. Harmonization of distinct longitudinal measures, measurement tools, and sampling rates across studies is challenging, but also opens up new opportunities to address cross-cutting scientific themes of interest.

Health behavior changes, such as prevention of suicidal thoughts and behaviors, smoking, drug use, and alcohol use; and the promotion of mental health, sleep, and physical activities, and decreases in sedentary behavior, are difficult to sustain. The ILHBN is a cooperative agreement network funded jointly by seven participating units within the National Institutes of Health to collaboratively study how factors that occur in individuals' everyday life and in their natural environment influence the success of positive health behavior changes. This article discusses how information collected using smartphones, wearables, and other devices can provide helpful active and passive reflections of the participants' extent of risk and resources at the moment for an extended period of time. However, successful engagement and retention of participants also require tailored adaptations of study designs, measurement tools, measurement intervals, study span, and device choices that create hurdles in integrating (harmonizing) data from multiple studies. We describe some of the challenges, opportunities, and solutions that emerged from harmonizing intensive longitudinal data under heterogeneous study and participant characteristics within the ILHBN, and share some tools and recommendations to facilitate future data harmonization efforts.

Toward a Digital Future in Bipolar Disorder Assessment: A Systematic Review of Disruptions in the Rest-Activity Cycle as Measured by Actigraphy.

Background: Disruptions in rest and activity patterns are core features of bipolar disorder (BD). However, previous methods have been limited in fully characterizing the patterns. There is still a need to capture dysfunction in daily activity as well as rest patterns in order to more holistically understand the nature of 24-h rhythms in BD. Recent developments in the standardization, processing, and analyses of wearable digital actigraphy devices are advancing longitudinal investigation of rest-activity patterns in real time. The current systematic review aimed to summarize the literature on actigraphy measures of rest-activity patterns in BD to inform the future use of this technology. Methods: A comprehensive systematic review using PRISMA guidelines was conducted through PubMed, MEDLINE, PsycINFO, and EMBASE databases, for papers published up to February 2021. Relevant articles utilizing actigraphy measures were extracted and summarized. These papers contributed to three research areas addressed, pertaining to the nature of rest-activity patterns in BD, and the effects of therapeutic interventions on these patterns. Results: Seventy articles were included. BD was associated with longer sleep onset latency and duration, particularly during depressive episodes and with predictive value for worsening of future manic symptoms. Lower overall daily activity was also associated with BD, especially during depressive episodes, while more variable activity patterns within a day were seen in mania. A small number of studies linked these disruptions with differential patterns of brain functioning and cognitive impairments, as well as more adverse outcomes including increased suicide risk. The stabilizing effect of therapeutic options, including pharmacotherapies and chronotherapies, on activity patterns was supported. Conclusion: The use of actigraphy provides valuable information about rest-activity patterns in BD. Although results suggest that variability in rhythms over time may be a specific feature of BD, definitive conclusions are limited by the small number of studies assessing longitudinal changes over days. Thus, there is an urgent need to extend this work to examine patterns of rhythmicity and regularity in BD. Actigraphy research holds great promise to identify a much-needed specific phenotypic marker for BD that will aid in the development of improved detection, treatment, and prevention options.

Inequality and mental healthcare utilisation among first-year university students in South Africa.

BACKGROUND: Addressing inequalities in mental healthcare utilisation among university students is important for socio-political transformation, particularly in countries with a history of educational exclusion. METHODS: As part of the WHO World Mental Health International College Student Initiative, we investigated inequalities in mental healthcare utilisation among first-year students at two historically "White" universities in South Africa. Data were collected via a web-based survey from first-year university students (n = 1402) to assess 12-month mental healthcare utilisation, common mental disorders, and suicidality. Multivariate logistic regression models were used to estimate associations between sociodemographic variables and mental healthcare utilisation, controlling for common mental disorders and suicidality. RESULTS: A total of 18.1% of students utilised mental healthcare in the past 12 months, with only 28.9% of students with mental disorders receiving treatment (ranging from 28.1% for ADHD to 64.3% for bipolar spectrum disorder). Of those receiving treatment, 52.0% used psychotropic medication, 47.3% received psychotherapy, and 5.4% consulted a traditional healer. Treatment rates for suicidal ideation, plan and attempt were 25.4%, 41.6% and 52.9%, respectively. In multivariate regression models that control for the main effects of mental health variables and all possible joint effects of sociodemographic variables, the likelihood of treatment was lower among males (aOR = 0.57) and Black students (aOR = 0.52). An interaction was observed between sexual orientation and first generation status; among second-generation students, the odds of treatment were higher for students reporting an atypical sexual orientation (aOR = 1.55), while among students with atypical sexual orientations, the likelihood of mental healthcare utilisation was lower for first-generation students (aOR = 0.29). Odds of treatment were significantly elevated among students with major depressive disorder (aOR = 1.88), generalised anxiety disorder (aOR = 2.34), bipolar spectrum disorder (aOR = 4.07), drug use disorder (aOR = 3.45), suicidal ideation (without plan or attempt) (aOR = 2.00), suicide plan (without attempt) (aOR = 3.64) and suicide attempt (aOR = 4.57). Likelihood of treatment increased with level of suicidality, but not number of mental disorders. CONCLUSION: We found very low mental healthcare treatment utilisation among first-year university students in South Africa, with enduring disparities among historically marginalised groups. Campus-based interventions are needed to promote mental healthcare utilisation by first-year students in South Africa, especially among male and Black students and first-generation students with atypical sexual orientations.

Accuracy of online survey assessment of mental disorders and suicidal thoughts and behaviors in Spanish university students. Results of the WHO World Mental Health- International College Student initiative.

OBJECTIVE: To assess the accuracy of WMH-ICS online screening scales for evaluating four common mental disorders (Major Depressive Episode[MDE], Mania/Hypomania[M/H], Panic Disorder[PD], Generalized Anxiety Disorder[GAD]) and suicidal thoughts and behaviors[STB] used in the UNIVERSAL project. METHODS: Clinical diagnostic reappraisal was carried out on a subsample of the UNIVERSAL project, a longitudinal online survey of first year Spanish students (18-24 years old), part of the WHO World Mental Health-International College Student (WMH-ICS) initiative. Lifetime and 12-month prevalence of MDE, M/H, PD, GAD and STB were assessed with the Composite International Diagnostic Interview-Screening Scales [CIDI-SC], the Self-Injurious Thoughts and Behaviors Interview [SITBI] and the Columbia-Suicide Severity Rating Scale [C-SSRS]. Trained clinical psychologists, blinded to responses in the initial survey, administered via telephone the Mini-International Neuropsychiatric Interview [MINI]. Measures of diagnostic accuracy and McNemar χ2 test were calculated. Sensitivity analyses were conducted to maximize diagnostic capacity. RESULTS: A total of 287 students were included in the clinical reappraisal study. For 12-month and lifetime mood disorders, sensitivity/specificity were 67%/88.6% and 65%/73.3%, respectively. For 12-month and lifetime anxiety disorders, these were 76.8%/86.5% and 59.6%/71.1%, and for 12-month and lifetime STB, 75.9%/94.8% and 87.2%/86.3%. For 12-month and lifetime mood disorders, anxiety disorders and STB, positive predictive values were in the range of 18.1-55.1% and negative predictive values 90.2-99.0%; likelihood ratios positive were in the range of 2.1-14.6 and likelihood ratios negative 0.1-0.6. All outcomes showed adequate areas under the curve [AUCs] (AUC>0.7), except M/H and PD (AUC = 0.6). Post hoc analyses to select optimal diagnostic thresholds led to improved concordance for all diagnoses (AUCs>0.8). CONCLUSION: The WMS-ICS survey showed reasonable concordance with the MINI telephone interviews performed by mental health professionals, when utilizing optimized cut-off scores. The current study provides initial evidence that the WMS-ICS survey might be useful for screening purposes.

Efficacy and cost-effectiveness of an unguided, internet-based self-help intervention for social anxiety disorder in university students: protocol of a randomized controlled trial.

BACKGROUND: Social anxiety disorder (SAD) is highly prevalent among university students, but the majority of affected students remain untreated. Internet- and mobile-based self-help interventions (IMIs) may be a promising strategy to address this unmet need. This study aims to investigate the efficacy and cost-effectiveness of an unguided internet-based treatment for SAD among university students. The intervention is optimized for the treatment of university students and includes one module targeting fear of positive evaluations that is a neglected aspect of SAD treatment. METHODS: The study is a two arm randomized controlled trial in which 200 university students with a primary diagnosis of SAD will be assigned randomly to either a wait-list control group (WLC) or the intervention group (IG). The intervention consists of 9 sessions of an internet-based cognitive-behavioral treatment, which also includes a module on fear of positive evaluation (FPE). Guidance is delivered only on the basis of standardized automatic messages, consisting of positive reinforcements for session completion, reminders, and motivational messages in response to non-adherence. All participants will additionally have full access to treatment as usual. Diagnostic status will be assessed through Structured Clinical Interviews for DSM Disorders (SCID). Assessments will be completed at baseline, 10 weeks and 6-month follow-up. The primary outcome will be SAD symptoms at post-treatment, assessed via the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS). Secondary outcomes will include diagnostic status, depression, quality of life and fear of positive evaluation. Cost-effectiveness and cost-utility analyses will be evaluated from a societal and health provider perspective. DISCUSSION: Results of this study will contribute to growing evidence for the efficacy and cost-effectiveness of unguided IMIs for the treatment of SAD in university students. Consequently, this trial may provide valuable information for policy makers and clinicians regarding the allocation of limited treatment resources to such interventions. TRIAL REGISTRATION: DRKS00011424 (German Clinical Trials Register (DRKS)) Registered 14/12/2016.

Barriers of mental health treatment utilization among first-year college students: First cross-national results from the WHO World Mental Health International College Student Initiative.

BACKGROUND: Although mental disorders and suicidal thoughts-behaviors (suicidal thoughts and behaviors) are common among university students, the majority of students with these problems remain untreated. It is unclear what the barriers are to these students seeking treatment. AIMS: The aim of this study is to examine the barriers to future help-seeking and the associations of clinical characteristics with these barriers in a cross-national sample of first-year college students. METHOD: As part of the World Mental Health International College Student (WMH-ICS) initiative, web-based self-report surveys were obtained from 13,984 first-year students in eight countries across the world. Clinical characteristics examined included screens for common mental disorders and reports about suicidal thoughts and behaviors. Multivariate regression models adjusted for socio-demographic, college-, and treatment-related variables were used to examine correlates of help-seeking intention and barriers to seeking treatment. RESULTS: Only 24.6% of students reported that they would definitely seek treatment if they had a future emotional problem. The most commonly reported reasons not to seek treatment among students who failed to report that they would definitely seek help were the preference to handle the problem alone (56.4%) and wanting to talk with friends or relatives instead (48.0%). Preference to handle the problem alone and feeling too embarrassed were also associated with significantly reduced odds of having at least some intention to seek help among students who failed to report that they would definitely seek help. Having 12-month major depression, alcohol use disorder, and suicidal thoughts and behaviors were also associated with significantly reduced reported odds of the latter outcome. CONCLUSIONS: The majority of first-year college students in the WMH-ICS surveys report that they would be hesitant to seek help in case of future emotional problems. Attitudinal barriers and not structural barriers were found to be the most important reported reasons for this hesitation. Experimental research is needed to determine whether intention to seek help and, more importantly, actual help-seeking behavior could be increased with the extent to which intervention strategies need to be tailored to particular student characteristics. Given that the preference to handle problems alone and stigma and appear to be critical, there could be value in determining if internet-based psychological treatments, which can be accessed privately and are often build as self-help approaches, would be more acceptable than other types of treatments to student who report hesitation about seeking treatment.

Lifetime and 12-month treatment for mental disorders and suicidal thoughts and behaviors among first year college students.

OBJECTIVES: Mental disorders and suicidal thoughts and behaviors (STB) are common and burdensome among college students. Although available evidence suggests that only a small proportion of the students with these conditions receive treatment, broad-based data on patterns of treatment are lacking. The aim of this study is to examine the receipt of mental health treatment among college students cross-nationally. METHODS: Web-based self-report surveys were obtained from 13,984 first year students from 19 colleges in eight countries across the world as part of the World Health Organization's World Mental Health-International College Student Initiative. The survey assessed lifetime and 12-month common mental disorders/STB and treatment of these conditions. RESULTS: Lifetime and 12-month treatment rates were very low, with estimates of 25.3-36.3% for mental disorders and 29.5-36.1% for STB. Treatment was positively associated with STB severity. However, even among severe cases, lifetime and 12-month treatment rates were never higher than 60.0% and 45.1%, respectively. CONCLUSIONS: High unmet need for treatment of mental disorders and STB exists among college students. In order to resolve the problem of high unmet need, a reallocation of resources may focus on innovative, low-threshold, inexpensive, and scalable interventions.

The cost of materialism in a collectivistic culture: predicting risky behavior engagement in Chinese adolescents.

The goals of the current study were to examine whether (a) negative events mediate the relationship between materialism and risky behavior engagement and (b) materialism moderates the relationship between stress and engagement in risky behaviors in Chinese youth. At Time 1, 406 adolescents (ages 14-19) from Yue Yang, China, completed measures assessing engagement in risky behaviors and the occurrence of negative events. Follow-up assessments occurred once a month for 6 months. In line with our hypotheses, results of hierarchical linear modeling analyses indicated that higher levels of negative events mediated the relationship higher levels of materialism and greater risky behavior engagement. In addition, adolescents who exhibited higher levels of materialism were more likely than adolescents possessing lower levels of materialism to report increased engagement in risky behaviors in response to negative life events. At the same time, the effect was only present in boys. Unexpectedly, girls who reported lower levels of materialism also exhibited increased engagement in risky behaviors in response to negative events.