The effect of parent-adolescent discrepancies in reports of familial dysfunction and depression on suicidal ideation in adolescents.

INTRODUCTION: Parents and adolescents are often discrepant in their reports of adolescent psychosocial factors. Few studies have addressed parent-adolescent discrepancies in subjective ratings of familial dysfunction and depression as longitudinal predictor variables, and none have done so in a treatment setting for adolescents with acute suicidality. This study examined how parent-adolescent discrepancies in familial dysfunction and depression impact adolescent treatment response in an intensive outpatient program for suicidality. METHODS: Adolescents (N = 315) were assessed at treatment entry and exit for familial dysfunction, depression, and suicidal ideation. Parents received parallel assessments of familial dysfunction and adolescent depression at each time point. A polynomial regression was conducted to determine whether parent-adolescent discrepancies in reports of familial dysfunction and depression at entry related to the treatment outcome of adolescent-reported depression and suicide ideation at exit. RESULTS: Significant discrepancies were present with on average adolescents reporting more depression and familial dysfunction than parents. Entry discrepancy in familial dysfunction (but not depression) predicted suicide ideation at exit. CONCLUSIONS: Our results suggest that parent-adolescent discrepancies in perception of familial dysfunction is a risk factor for poor outcomes in suicidal youth and might be a fruitful target in treatment programs.

Characterizing patterns of substance use in trauma exposed youth.

OBJECTIVE: Previous work investigating the impact of childhood trauma on substance use and co-occurring psychiatric disorders has primarily been conducted in adults or on specific trauma types. This limits understanding of traumas impact in childhood and how different types of traumas play a role. We sought to characterize substance use in a sample of trauma-exposed youth in the context of psychiatric comorbidities. METHOD: 1152 youth from the Texas Childhood Trauma Research Network (TX-CTRN) that were exposed to at least one trauma meeting DSM-5 Criterion A were assessed for current substance use and psychiatric diagnoses. Latent class analysis was used to identify patterns of substance use. To characterize these patterns, we examined if demographics, number of trauma types experienced, or childhood psychiatric disorders predicted class membership. RESULTS: We identified four primary patterns of substance use: Non-use (66.1%), predominantly alcohol use (19.7%), predominantly cannabis use (4.5%), and polysubstance use (9.7%). Compared to the non-users, polysubstance users tended to be older, Non-Hispanic White, have experienced more types of trauma. They were also more likely to have fulfilled diagnostic criteria for suicidality and ADHD. Comparisons among the substance using classes were more nuanced. CONCLUSION: The findings highlight the need for universal assessments of trauma, substance misuse, and mental health symptoms in youth as the presence or absence of their co-occurrence has implications for treatment.

Examining a Resilience Mental Health App in Adolescents: Acceptability and Feasibility Study.

BACKGROUND: Resilience is defined as the ability to rely on internal characteristics and external strengths to adapt to adverse events. Although universal resilience-enhancing programs are effective for adolescents, there is a need for interventions that are more easily accessible and can be customized for individual teens. Phone apps are easy to use, can be tailored to individuals, and have demonstrated positive effects for mental health outcomes. OBJECTIVE: This study aimed to examine the feasibility and acceptability of a resilience app for adolescents. This app aimed to enhance resilience through modules focused on depression prevention, stress management, and healthy lifestyle approaches containing videos, measures, and practice suggestions. Furthermore, the study aimed to evaluate the effect of short-term app use on changes in resilience. METHODS: In study 1, individual interviews and focus groups were conducted with adolescents, parents, teachers, and clinicians to discuss possible incentives for using a mental health app, the benefits of app use, and concerns associated with app use. Feedback from study 1 led to ideas for the prototype. In study 2, individual interviews and focus groups were conducted with adolescents, parents, teachers, and clinicians to gather feedback about the resilience app prototype. Feedback from study 2 led to changes in the prototype, although not all suggestions could be implemented. In study 3, 40 adolescents used the app for 30 days to determine feasibility and acceptability. Additionally, resilience and secondary mental health outcomes were measured before and after app use. Dependent samples 2-tailed t tests were conducted to determine whether there were changes in resilience and secondary mental health outcomes among the adolescents before and after app use. RESULTS: Multiple themes were identified through study 1 individual interviews and focus groups, including app content, features, engagement, benefits, concerns, and improvement. Specifically, the adolescents provided helpful suggestions for making the prototype more appealing and functional for teen users. Study 2 adolescents and adults reported that the prototype was feasible and acceptable through the Computer System Usability Questionnaire (mean 6.30, SD 1.03) and Mobile App Rating Scale (mean 4.08, SD 0.61). In study 2, there were no significant differences in resilience and mental health outcomes after using the app for 30 days. There was variation between the participants in the extent to which they used the app, which may have led to variation in the results. The users appeared to prefer the depression module and survey sections, which provided mental health feedback. CONCLUSIONS: Qualitative and quantitative data provide evidence that youth are interested in a resilience mental health app and that the current prototype is feasible. Although there were no significant mental health changes in study 3 users, practical implications and future directions are discussed for mental health app research.

The More the Better, Only in the Longer Term: A Cluster Randomized Controlled Trial to Evaluate a Compound Intervention Among Mainland Chinese Immigrants in Hong Kong.

Barriers to adaptation faced by mainland Chinese immigrants to Hong Kong can be reduced by improving two targets of adaptation: information about negotiating their new environment and psychological well-being. We developed and evaluated a Compound intervention to address these two domains simultaneously and compared its effects to two separate interventions exclusively targeting either information about Hong Kong or psychological well-being. This cluster randomized controlled trial assigned 251 immigrants to an information provision arm (IP, n = 84) targeting knowledge and adaptation difficulties, a psychological well-being enhancement arm (WBE, n = 80) targeting resilience and mental health, or a Compound arm (i.e., IP + WBE, n = 87). The Compound arm showed stronger effects from baseline to postintervention on knowledge than the WBE arm. From postintervention to 6-month follow-up, the Compound arm showed better sustained effects on knowledge and adaptation difficulties than the IP arm and on resilience and mental health than the WBE arm. Additionally, participants in the Compound arm with more baseline depressive symptoms showed greater improvements in adaptation difficulties and general mental health than those with fewer symptoms. The study demonstrated the longer-term effectiveness of the Compound intervention and its greater benefits for immigrants with more depressive symptoms.

Persistent suicidal ideation in a large intensive outpatient adolescent population sample: A preliminary report on the role of sleep disturbance.

Sleep disturbance is a unique, yet understudied, risk factor for suicidal thoughts and behaviors (STBs). The present study sought to explore the relationship between suicidal ideation (SI) and self-reported sleep disturbance in a sample of adolescents in an intensive outpatient program targeting suicidality (N = 691). Analyses conducted include paired samples t tests, multiple linear regression, and analysis of variance to examine group differences in sleep disturbance over time. Sleep disturbance and SI were associated at each timepoint, and sleep disturbance at admission predicted SI at discharge. Those with the most severe SI at discharge indicated increased sleep disturbance relative to admission, whereas those reporting no SI at discharge nearly resolved all sleep difficulties. Future studies should utilize objective sleep measures, longitudinal assessments, and include a more diverse sample to better inform the relationship of sleep and SI. These findings suggest that directly managing sleep disturbance during treatment could decrease the risk of STBs.

Borderline personality features influence treatment response to suicide prevention.

BACKGROUND: Suicide is a notable risk for individuals with features of borderline personality disorder. Given the centrality of interpersonal difficulties in this disorder, we proposed that the negative interpersonal cognitions (perceived burdensomeness and thwarted belongingness) identified by the Interpersonal Theory of Suicide (IPTS) may explain the associations between suicidal ideation and borderline personality features. METHOD: Participants were 322 suicidal youth (74% girls) aged 11-18 years (M, SD = 14.74, 1.6) in an intensive outpatient program in the southwest United States. Youth completed measures assessing borderline personality features at program entry, and suicidal ideation and IPTS variables at entry and exit. RESULTS: Borderline personality features did not moderate associations of IPTS variables and suicidal ideation. For the entire sample, changes in suicidal ideation from entry to discharge occurred in tandem with changes in perceived burdensomeness and depressive symptoms, but not thwarted belongingness. Youth with elevated borderline personality features entered with greater suicidal ideation, but improved more from treatment entry to exit. Regardless of level of borderline personality features, changes in negative interpersonal cognitions over treatment were associated with changes in suicidal ideation. LIMITATIONS: Self-report measures and lack of sample diversity are study limitations. CONCLUSIONS: This research highlights the clinical utility of the IPTS variables and the importance of promoting competence and interpersonal connectedness when treating this population. Findings indicate that the IPTS variables carry the same fundamental information for contributing to suicidal ideation, regardless of level of borderline personality features.

Fearlessness about death and suicide planning predict lethality of adolescent suicide attempts during and following treatment.

INTRODUCTION: The rate of adolescent suicide attempt has increased drastically over the past 10 years. However, little is known regarding what predicts a more versus less lethal attempt, which is of critical interest to clinicians managing this at-risk population. We sought to extend the study of lethality in adolescents by exploring its relationship with two recognized risk-factors for suicide attempt: fearlessness about death (FAD) and suicide planning. METHODS: Participants (N = 254) were administered measures of FAD and depressive symptoms upon entering intensive outpatient treatment for adolescents exhibiting suicidal thoughts and behaviors. Attempts made between treatment entry and 6 months following discharge (n = 47) were scored on a 4-point ordinal scale of lethality. The resulting continuum ranged from no attempt to attempts of low to moderate levels of lethality. RESULTS: FAD and suicide planning distinguished between levels of lethality of future attempt at the bivariate and multivariate level. FAD's predictive relationship with lethality while controlling for age, sex, depression, and prior attempt diminished when suicide planning was covaried. CONCLUSION: FAD and suicide planning significantly predicted more versus less lethal future attempts in our sample of adolescents in a clinical setting. Our findings suggest that FAD influences the lethality of a future attempt by promoting planning for suicide. More studies are needed to assess whether the brief FAD scale might be a valuable adjunct in the clinical management of youth with suicidal thoughts and behaviors.

"They stand in the middle now": Pathways to meeting psychological needs by adolescents who are refugees from sub-Saharan Africa.

OBJECTIVES: This study explored the psychological needs of refugee youth from sub-Saharan Africa resettled in a large city in Southwest United States. We utilized the framework of Basic Psychological Needs Theory (Deci & Ryan, 2000) which proposes that competence, relatedness, and autonomy are universal psychological needs. We examined the challenges to meeting these needs and resolutions to these challenges. Integral to understanding these needs was to place them in the context of a bicultural model of adaptation. Of particular interest was discovering how these young people negotiate and reconcile home and host cultural demands while meeting needs. METHOD: From July 2019 to August 2020, semistructured individual interviews (N = 44) were completed with youth, parents, and cultural experts. Data were analyzed using a hybrid inductive and deductive approach and thematic content analysis. RESULTS: Active engagement, assertion, and self-advocacy were delineated as important pathways to achieve competence. Relatedness needs were served by inclusive ties, and frequently included other "outsiders." Autonomy came from self-sufficiency, agency, and "voice." Altruism was common, extending beyond ethnic community, and promoted competence, relatedness, and empowerment. Conflicts between family and host culture were managed by accepting parental authority. Parents contributed to integrating home and host cultures by flexibly interpreting traditional rules. CONCLUSIONS: Our findings illustrate the strengths of these youth who manage tremendous challenges to meeting their psychological needs. We highlight how in the process of cultural adaptation they retain ties to their home culture. They choose diversity in their relationships and find agency and purpose by supporting others. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Promoting Fruit and Vegetable Intake in Parents: A Cluster Randomised Controlled Trial.

We conducted a cluster randomised controlled trial of parents in 56 primary schools and community service centres (clusters) to evaluate the effectiveness of a single-session workshop on promoting more fruit and vegetable (FV) intake. A total of 803 parents were randomised to the FV intervention arm (16 clusters, n = 197), the more appreciation control arm (19 clusters, n = 270), or the less criticism control arm (21 clusters, n = 336). The FV intake of the FV arm was compared with that of the combined more appreciation or less criticism (MALC) arm. Both arms received a 2 h workshop: (i) the FV arm on increasing FV consumption and related food literacy; (ii) the MALC arm on increasing appreciation or reducing criticism of children. Primary outcomes were FV consumption per day in the past week assessed at baseline, 2-weeks, and 6-weeks. Secondary outcomes were behavioural determinants proposed by the Health Action Process Approach (HAPA), including outcome expectancies, self-efficacy, intention, and planning behaviour. The FV arm had a greater increase in FV consumption than the MALC arm, with large effect sizes (d: 0.97-1.08) and improvements in behavioural determinants with small effect sizes at all time points (d: 0.19-0.43). Our study was the first population-based randomised controlled trial to show that a brief, single 2 h HAPA-based workshop was effective in promoting fruit and vegetable intake in parents.

Validation of Fearlessness about Death Scale in adolescents.

Recent theories of suicide behavior have proposed a risk factor that differentiates suicide ideators from suicide attempters: Suicide capability. Fearlessness about death, one component of capability, has predicted the likelihood of a future attempt in adult samples. Although there is preliminary evidence about its value in youth, the fearlessness about death scale (FAD) has not yet been validated in clinical adolescents. We sought to examine the psychometric properties of this scale in adolescents at high risk for making a future suicide attempt. Youth who were evaluated for an intensive outpatient program (IOP) for suicidal adolescents (N = 496; M, SD for age = 14.78, 1.59) reported lifetime history of suicide attempts and NSSI, suicide ideation, depressive symptoms, and completed the FAD at entry and at discharge (n = 329). Confirmatory factor analysis showed structural validity of the FAD scale and its invariance across age, sex, and time. Independent t-tests indicated that FAD scores distinguished between those with and without NSSI, as well as those with single versus multiple attempts. When depression was covaried in logistic regression analyses, FAD's relationship with suicide attempt history persisted, showing the construct's divergence from depression. Our findings present psychometric validity in adolescents for a widely used scale developed for adults. This validation offers confidence that this promising risk factor can be adequately investigated in adolescents. If future studies can confirm its predictive validity, the brevity of this scale would make it a practical addition to a clinical assessment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Implementing the interpersonal theory of suicide to improve outcomes in suicidal adolescents: A pilot trial.

INTRODUCTION: The Interpersonal Psychological Theory of Suicide proposes two constructs that serve as a final common pathway to suicidal ideation: thwarted belongingness and perceived burdensomeness. There have been few translations of this theory to clinical care. This study aimed to address this limitation by targeting burden cognitions with novel interventions. METHODS: A pilot clinical trial was conducted in an evidence-based intensive outpatient program for suicidal youth. Participants were 123 adolescents who completed measures at intake, discharge, and one-month follow-up. The experimental group consisted of standard care plus study interventions, which was compared with an active control group of standard care. Feedback on intervention acceptability was gathered through qualitative interviews with parents and adolescents. RESULTS: There was a statistically significant drop in thwarted belongingness at discharge and an improvement in perceived burdensomeness at discharge (not statistically significant, small effect size). Feedback on acceptability was favorable and supported implementation. CONCLUSION: This study adds to the literature by being the first to utilize the construct of perceived burdensomeness in clinical interventions for suicidal youth; illustrating one potential avenue for translating theory to practice. The unexpected effects on thwarted belongingness have implications for the role of these constructs in a treatment setting.

Refinement of the Role of Hopelessness in the Interpersonal Theory of Suicide: An Exploration in an Inpatient Adolescent Sample.

Hopelessness is a well-established risk factor for suicidal ideation. Recent research has indicated that hopelessness can be split into two subsets: pessimism (PESS) and lack of optimism (LOO) and that LOO is more salient of the two in predicting suicide ideation (SI). The aim of this study was to examine the relationship of PESS and LOO to SI in the context of the Interpersonal Psychological Theory of Suicide (IPTS). Participants were 294 inpatient adolescents. LOO but not PESS was associated with SI. LOO interacted with the IPTS variable of perceived burdensomeness to differentiate between passive and active SI, partly consistent with the theory. These results support the value of separating the two components of hopelessness in understanding adolescent SI.

A Moderated Mediation Analysis on the Association Between Perceived Discrimination and Physical Symptoms Among Immigrant Women from Mainland China into Hong Kong: Evidence from the FAMILY Cohort.

With a research focus on the possible impact of perceived discrimination on physical symptoms, this study examined a moderated mediation model that depressive symptoms would mediate the association between perceived discrimination and physical symptoms, and family satisfaction would show moderating effects on both depressive and physical symptoms among immigrants. Immigrant women from Mainland China into Hong Kong (N = 966) completed a cross-sectional survey. Depressive symptoms mediated the association between perceived discrimination and physical symptoms. Family satisfaction moderated the association between perceived discrimination and depressive symptoms that participants with lower family satisfaction showed a stronger association. However, family satisfaction did not moderate with perceived discrimination or depressive symptoms to predict physical symptoms. Our findings demonstrated the health consequences of perceived discrimination. Development of resilience programs, particularly with a focus of strengthening family resources, may in tandem help immigrants manage their experiences with discrimination.

Fearlessness about death predicts adolescent suicide attempt: A preliminary analysis.

OBJECTIVE: Several theories of suicide suggest that people will only attempt suicide if they have both the desire to die and the capability for suicide. Fearlessness about death is a key component of capability for suicide. There is little information in the literature about the prospective relationship between fearlessness about death and suicide attempt in adolescents. METHOD: We obtained baseline fearlessness about death from adolescents (N = 122; ages 12-18; 80% girls; 82% Caucasian) who received intensive outpatient treatment for active suicidal ideation and/or a recent attempt. We tested if fearlessness about death at treatment entry predicted an attempt (n = 14) between entry and six-month follow-up after discharge from the program. RESULTS: Fearlessness about death significantly predicted the presence of an attempt between treatment entry and six-month follow-up after controlling for common covariates (Quade F = 2.15, p < .02). CONCLUSIONS: In a preliminary analysis of a group of suicidal adolescents, fearlessness about death was a significant independent predictor of attempt between treatment entry and six months post-discharge, even when controlling for other commonly cited risk factors.

A Community-Based Lifestyle-Integrated Physical Activity Intervention to Enhance Physical Activity, Positive Family Communication, and Perceived Health in Deprived Families: A Cluster Randomized Controlled Trial.

Background: Zero-time exercise (ZTEx) is an approach integrating simple strength- and stamina-enhancing physical activity into daily life. The study evaluated the effectiveness of a community-based lifestyle-integrated physical activity intervention using ZTEx to enhance participants' physical activity, family communication, perceived health and happiness, and family harmony. Methods: A parallel group, cluster randomized controlled trial was conducted in a sample of 673 participants from eight Integrated Family Service Centers in Hong Kong. The experimental group (n = 316) received a physical activity intervention. The control group (n = 357) received information on healthy eating. Both groups received three face-to-face intervention sessions (totalling 6 h and 30 min) and 16 text messages. The primary outcome was the change in days spent engaged in ZTEx. Secondary outcomes included changes in sitting time, days engaged in moderate or vigorous physical activities, family communication (encouraging and engaging family members in ZTEx), dietary habits, perceived health and happiness, and family harmony. Self-administered questionnaires were used at baseline and at 3, 6, and 12 months. Mixed effects models with intention-to-treat analysis was used. Results: Compared with the control group at 3 months, the experimental group showed significantly greater increases of 1.3 days spent doing ZTEx (Cohen's d: 0.60), 0.3 days spent doing moderate physical activity (Cohen's d: 0.08), 0.3 days encouraging family members to do ZTEx (Cohen's d: 0.16), and 0.7 days doing ZTEx with family members (Cohen's d: 0.39) during the 7 days prior. At 3 months, the experimental group also showed a significantly greater improvement in perceived health, by a score of 0.2 (Cohen's d: 0.14). The effect sizes ranged from small to medium, with similar intervention effects at the 6-month and 1-year assessments. Compared with the experimental group, the control group showed a significantly greater reduction of 0.4 days on which sweetened beverages were consumed (95% CI: 0.01, 0.9, p < 0.05, Cohen's d: 0.28). The qualitative results supported the quantitative findings. Conclusions: Our findings show that a community-based lifestyle-integrated physical activity (PA) intervention can enhance physical activity, family communication, and perceived health in deprived families in Hong Kong. Trial registration: The research protocol was retrospectively registered at the National Institutes of Health (identifier number: NCT02601534) on November 10, 2015.

Body Dissatisfaction and Mental Health Outcomes of Youth on Gender-Affirming Hormone Therapy.

OBJECTIVES: Our first aim was to examine baseline differences in body dissatisfaction, depression, and anxiety symptoms by gender, age, and Tanner (ie, pubertal) stage. Our second aim was to test for changes in youth symptoms over the first year of receiving gender-affirming hormone therapy. Our third aim was to examine potential differences in change over time by demographic and treatment characteristics. Youth experiences of suicidal ideation, suicide attempt, and nonsuicidal self-injury (NSSI) are also reported. METHODS: Participants (n = 148; ages 9-18 years; mean age 14.9 years) were receiving gender-affirming hormone therapy at a multidisciplinary program in Dallas, Texas (n = 25 puberty suppression only; n = 123 feminizing or masculinizing hormone therapy). Participants completed surveys assessing body dissatisfaction (Body Image Scale), depression (Quick Inventory of Depressive Symptoms), and anxiety (Screen for Child Anxiety Related Emotional Disorders) at initial presentation to the clinic and at follow-up. Clinicians completed the Quick Inventory of Depressive Symptoms and collected information on youth experiences of suicidal ideation, suicide attempt, and NSSI. RESULTS: Affirmed males reported greater depression and anxiety at baseline, but these differences were small (P < .01). Youth reported large improvements in body dissatisfaction (P < .001), small to moderate improvements in self-report of depressive symptoms (P < .001), and small improvements in total anxiety symptoms (P < .01). No demographic or treatment-related characteristics were associated with change over time. Lifetime and follow-up rates were 81% and 39% for suicidal ideation, 16% and 4% for suicide attempt, and 52% and 18% for NSSI, respectively. CONCLUSIONS: Results provide further evidence of the critical role of gender-affirming hormone therapy in reducing body dissatisfaction. Modest initial improvements in mental health were also evident.

A cluster randomized controlled trial of more appreciation and less criticism in Hong Kong parents.

Our cluster randomized controlled trial tested, respectively, 2 brief interventions to promote more appreciation and less criticism in Hong Kong Chinese parents toward their children and to enhance family well-being. We randomized 56 primary schools and community service centers (clusters of parents of primary grades 3-6 students) to the more appreciation (MA) or less criticism (LC) intervention arms, or fruit and vegetable control arm (FV). A total of 803 parents received a 2-hr workshop on increasing appreciation (19 clusters, n = 270), reducing criticism (21 clusters, n = 336), or increasing fruit and vegetable consumption (16 clusters, n = 197) and were assessed at baseline, immediately after the workshop, at 2 weeks, and at 6 weeks. Primary outcomes were parents' frequency of appreciation and criticism behaviors. Secondary outcomes were family well-being and potential behavioral determinants proposed by the Health Action Process Approach, including outcome expectancies, self-efficacy, intention, and planning behavior. At 6 weeks, the MA and LC arms reported greater increases in appreciation behavior than the FV arm, and the LC arm reported greater decreases in criticism than the FV arm, with small effect sizes. Specific improvements were also observed in the behavioral determinants at various time points compared with the FV arm. Similar improvements in family well-being were observed across all arms. Our findings were the first to show that brief Health Action Process Approach-based workshops on Chinese parents were effective in promoting positive parental behaviors. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Editorial: Extending Parent-Child Interaction Therapy to Preschool Children Who Are Depressed.

The World Health Organization lists depression as the single largest contributor to global disability. More than 300 million people worldwide are estimated to suffer from this disorder. Success in managing depression once it begins is limited, with questions about the extent of the effectiveness of antidepressant medications and psychosocial treatments on depression in youths.1,2 Depression is associated with a host of attendant comorbidities, such as substance use and suicidal and nonsuicidal self-injury, which are difficult to treat and wreak further havoc on the lives of youths and their families. There are few available nonpharmacological treatments for preschool depression. Parent-Child Interaction therapy (PCIT) is an evidence-based program3 designed to address externalizing behaviors in preschool children. Luby et al.4 present data on the effectiveness of a module that extends PCIT to address symptoms of preschool depression (PCIT-ED). Strengths of this study are the extension of a well-developed program to a group in high need, a sequential approach to examining effects, and the measurement of neural response as an outcome. The study is an exciting contribution to the care of preschool children. It has implications for early intervention, for altering trajectories of negative parent-child interactions in vulnerable families, and for personalized approaches to care.

The association between baseline insomnia symptoms and future suicide attempts within an intensive outpatient treatment program for suicide.

This study examines the prospective relationship between insomnia symptoms and suicide attempts in high-risk youth. We obtained depressive symptoms, insomnia symptoms, and suicide ideation measures from clinical records of 206 adolescents ages 12-17 at entry and discharge from a suicide prevention intensive outpatient program. Information about whether the participant made a suicide attempt was available through six months after discharge. Patients were mainly girls (79.1%; n = 163) with depression (89.8%; n = 185). Associations between insomnia symptoms, attempts within 6 months of discharge, persistent insomnia symptoms, and suicide ideation at discharge were tested with multiple regression analyses. Entry insomnia symptoms were prospectively associated with attempts when controlling for age, sex, and previous attempts, but insomnia symptoms at discharge were not. Suicide ideation at discharge was associated both with entry insomnia symptoms and attempts within 6 months of discharge. When entry and discharge suicide ideation were controlled, the association between entry insomnia symptoms and attempts lost significance. However, the association between discharge ideation and attempts remained significant. Insomnia symptoms contribute indirectly to suicide attempt risk after discharge. Intensive treatment for ideation and reducing insomnia symptoms could reduce discharge suicide risk and subsequent suicide attempts.