Development and codesign of flourish: A digital suicide prevention intervention for LGBTQ+ youth who have experienced online victimization.

Background: LGBTQ+ youth experience disproportionately high rates of online victimization (OV), referring to harmful remarks, images, or behaviors in online settings, which is associated with suicidal risk. Current services have gaps in supporting LGBTQ+ youth facing OV events. To address these gaps, this study aims to develop Flourish, a digital suicide prevention intervention for LGBTQ+ youth who have experienced OV. Methods: Qualitative interviews were conducted with 20 LGBTQ+ youth with past-year history of OV and lifetime history of suicidality, 11 of their parents, and 10 LGBTQ+-serving professionals. Subsequently, an iterative codesign process was conducted with 22 youth through individual and group design sessions, followed by usability testing. Data were recorded and transcribed. Qualitative interviews were analyzed using a qualitative description approach, and data from design sessions and usability testing were analyzed using rapid qualitative techniques. Results: Interviews with youth, parents, and professionals suggested preferences for Flourish to be a partially automated, text message intervention leveraging web-based content that is a safe space for LGBTQ+ youth to seek support for OV through education, coping skills, and help-seeking resources. School and mental health services professionals considered the potential for implementing Flourish within youth services settings. Usability testing, assessed through the System Usability Scale, yielded an average rating of 91, indicating excellent perceived usability. Conclusions: Flourish has potential to be an acceptable intervention to support LGBTQ+ youth following OV. Future steps will include testing the feasibility and efficacy of Flourish and further examining Flourish's potential for implementation within services for LGBTQ+ youth.

Middle School Students' Experiences with Cyberbullying and Perspectives Toward Prevention and Bystander Intervention in Schools.

Cyberbullying is a growing problem for middle school students. Bystander interventions that train witnesses to positively intervene can prevent cyberbullying. Through six focus groups, we explored forty-six middle school students' experiences with cyberbullying and opportunities for school-based prevention programs to encourage positive bystander behavior. Focus groups were recorded, transcribed, and analyzed using content analysis. Students viewed cyberbullying as an important problem with significant consequences. They noted hesitancy in reporting to parents and school personnel and felt more comfortable discussing cyberbullying with a near-peer (e.g., older sibling or friend). Students desired combining school-based and online programming with near-peer mentorship. This study suggests need for targeted prevention programs that center middle school students' lived experiences with cyberbullying and their preferences for learning and utilizing positive bystander strategies.

Development of An Ecological Momentary Assessment of the Impact of Social Media Use Among Suicidal Adolescents.

OBJECTIVE: We aimed to develop an ecological momentary assessment (EMA) measure and sampling protocol to assess the near-term impact of experiences with social media use (SMU) that are associated with risk and protective factors for adolescent suicide. METHODS: To develop the EMA measure, we consulted literature reviews and conducted focus groups with the target population, adolescents at risk for suicide. Subsequently, we refined the measure through interviews with experts and cognitive interviews with adolescents, through which we explored adolescents' thought processes as they considered questions and response options. Data were recorded, transcribed, and analyzed using thematic analysis. RESULTS: The initial measure had 37 items assessing a range of harmful and beneficial aspects of SMU. Through expert and cognitive interviews, we refined the measure to 4 pathways assessing positive and negative experiences with SMU as well as positive and negative in-person interactions. Each pathway included a maximum of 11 items, as well as 2 items pertaining to SMU at nighttime to be assessed once daily. Acceptable targets the EMA measure's sampling protocol included a 10-day data collection window with text message-based prompts to complete the measure triggered 2-4 times daily. CONCLUSIONS: By assessing a range of risk and protective factors for youth suicide, while using methods to reduce participant burden, we established content validity for the EMA measure and acceptability for the sampling protocol among youth at high risk of suicide.HIGHLIGHTSDevelopment of an ecological momentary assessment measure and sampling protocolExploring brief momentary assessment of social media's impact on adolescent suicidal riskMulti-phase approach to establishing content validity and an acceptable sampling protocol.

Centering Lived Experience in Developing Digital Interventions for Suicide and Self-injurious Behaviors: User-Centered Design Approach.

BACKGROUND: The prevalence of self-injurious thoughts and behaviors (SITB) signals a growing public health crisis. Despite a recognized need for improved and scalable interventions, the field of SITB intervention faces several challenges: existing interventions are often time and resource intensive, most individuals with SITB do not seek formal mental health care, and efficacious treatments are characterized by small effects. Combined, these challenges indicate a need for improved SITB interventions for individuals in formal treatment and those who are not treatment engaged but are at high risk of worsening mental health and future suicide attempts. OBJECTIVE: We present a methodological approach and set of techniques that may address these challenges by centering the lived experience of individuals with SITB in the process of developing needed services: user-centered design (UCD). METHODS: We highlight the value of UCD in the context of digital interventions for SITB by describing the UCD approach and explicating how it can be leveraged to include lived experience throughout the development and evaluation process. We provide a detailed case example highlighting 3 phases of the early development process that can be used to design an intervention that is engaging and meets end-user needs. In addition, we point to novel applications of UCD to complement new directions in SITB research. RESULTS: In this paper, we offer a 2-pronged approach to meet these challenges. First, in terms of addressing access to effective interventions, digital interventions hold promise to extend the reach of evidence-based treatments outside of brick-and-mortar health care settings. Second, to address challenges related to treatment targets and engagement, we propose involving individuals with lived experience in the design and research process. CONCLUSIONS: UCD offers a well-developed and systematic process to center the unique needs, preferences, and perceived barriers of individuals with lived SITB experience in the development and evaluation of digital interventions.

Social media use and prospective suicidal thoughts and behaviors among adolescents at high risk for suicide.

OBJECTIVE: To examine the relationship between social media use and suicidal thoughts and behaviors among adolescents in the first 30 days of an intensive outpatient program (IOP) for depression and suicidality. METHOD: Participants included 100 adolescents who enrolled in an IOP for depression and suicidality and completed baseline measures of social media and weekly measures of depression and suicidal thoughts and behaviors at clinical visits over the next month. RESULTS: Lower levels of social media use (overall and messaging) were associated with a greater likelihood of having suicidal ideation with plan over the next 30 days. There was no effect on suicidal behavior. Multilevel modeling indicated no main effects of social media use on depression or average days of suicidal thoughts. However, individuals with lower levels of social media use maintained more depression symptoms and days with passive death wish across the first month of treatment. CONCLUSIONS: Among adolescents at high risk for suicide, less engagement in social media may reflect social anhedonia or withdrawal, which may heighten risk for more severe suicidal ideation or impede initial treatment. Findings highlight the importance of considering social media as an additional context when assessing social dysfunction in treatment for depression and suicidality.

Automated Monitoring of Suicidal Adolescents' Digital Media Use: Qualitative Study Exploring Acceptability Within Clinical Care.

BACKGROUND: Monitoring linguistic cues from adolescents' digital media use (DMU; ie, digital content transmitted on the web, such as through text messages or social media) that could denote suicidal risk offers a unique opportunity to protect adolescents vulnerable to suicide, the second leading cause of death among youth. Adolescents communicate through digital media in high volumes and frequently express emotionality. In fact, web-based disclosures of suicidality are more common than in-person disclosures. The use of automated methods of digital media monitoring triggered by a natural language processing algorithm offers the potential to detect suicidal risk from subtle linguistic units (eg, negatively valanced words, phrases, or emoticons known to be associated with suicidality) present within adolescents' digital media content and to use this information to respond to alerts of suicidal risk. Critical to the implementation of such an approach is the consideration of its acceptability in the clinical care of adolescents at high risk of suicide. OBJECTIVE: Through data collection among recently suicidal adolescents, parents, and clinicians, this study examines the current context of digital media monitoring for suicidal adolescents seeking clinical care to inform the need for automated monitoring and the factors that influence the acceptance of automated monitoring of suicidal adolescents' DMU within clinical care. METHODS: A total of 15 recently suicidal adolescents (aged 13-17 years), 12 parents, and 10 clinicians participated in focus groups, qualitative interviews, and a group discussion, respectively. Data were recorded, transcribed, and analyzed using thematic analysis. RESULTS: Participants described important challenges to the current strategies for monitoring the DMU of suicidal youth. They felt that automated monitoring would have advantages over current monitoring approaches, namely, by protecting web-based environments and aiding adolescent disclosure and support seeking about web-based suicidal risk communication, which may otherwise go unnoticed. However, they identified barriers that could impede implementation within clinical care, namely, adolescents' and parents' concerns about unintended consequences of automated monitoring, that is, the potential for loss of privacy or false alerts, and clinicians' concerns about liability to respond to alerts of suicidal risk. On the basis of the needs and preferences of adolescents, parents, and clinicians, a model for automated digital media monitoring is presented that aims to optimize acceptability within clinical care for suicidal youth. CONCLUSIONS: Automated digital media monitoring offers a promising means to augment detection and response to suicidal risk within the clinical care of suicidal youth when strategies that address the preferences of adolescents, parents, and clinicians are in place.

Natural language processing and machine learning of electronic health records for prediction of first-time suicide attempts.

OBJECTIVE: Limited research exists in predicting first-time suicide attempts that account for two-thirds of suicide decedents. We aimed to predict first-time suicide attempts using a large data-driven approach that applies natural language processing (NLP) and machine learning (ML) to unstructured (narrative) clinical notes and structured electronic health record (EHR) data. METHODS: This case-control study included patients aged 10-75 years who were seen between 2007 and 2016 from emergency departments and inpatient units. Cases were first-time suicide attempts from coded diagnosis; controls were randomly selected without suicide attempts regardless of demographics, following a ratio of nine controls per case. Four data-driven ML models were evaluated using 2-year historical EHR data prior to suicide attempt or control index visits, with prediction windows from 7 to 730 days. Patients without any historical notes were excluded. Model evaluation on accuracy and robustness was performed on a blind dataset (30% cohort). RESULTS: The study cohort included 45 238 patients (5099 cases, 40 139 controls) comprising 54 651 variables from 5.7 million structured records and 798 665 notes. Using both unstructured and structured data resulted in significantly greater accuracy compared to structured data alone (area-under-the-curve [AUC]: 0.932 vs. 0.901 P < .001). The best-predicting model utilized 1726 variables with AUC = 0.932 (95% CI, 0.922-0.941). The model was robust across multiple prediction windows and subgroups by demographics, points of historical most recent clinical contact, and depression diagnosis history. CONCLUSIONS: Our large data-driven approach using both structured and unstructured EHR data demonstrated accurate and robust first-time suicide attempt prediction, and has the potential to be deployed across various populations and clinical settings.

Social Media Use and Monitoring for Adolescents With Depression and Implications for the COVID-19 Pandemic: Qualitative Study of Parent and Child Perspectives.

BACKGROUND: Although youth report many positive experiences with social media (SM) use in their daily lives, adolescents with depression are more vulnerable to the risks of SM use than adolescents without depression. Parents protect adolescents with depression from the risks of SM use by monitoring their child's SM activity; however, this comes into conflict with the adolescent's need for autonomy in their web-based communication. The implications of SM use and monitoring for adolescents with depression and their parents are of particular relevance to the COVID-19 pandemic, as rates of SM use have increased in response to physical distancing measures. OBJECTIVE: This study aims to explore parent and child perspectives regarding the use and function of SM in the daily lives of adolescents with depression and parents' perceptions of and experience with monitoring their child's SM use. METHODS: We conducted qualitative interviews with adolescents with depression (n=23) and one parent of each adolescent (n=23) between July 2013 and September 2014. The adolescents were patients seeking treatment for depression in Pittsburgh, Pennsylvania. Data analysis included dyadic analysis of the adolescents' and parents' perspectives and qualitative descriptions of individual parent interviews to explore their experiences with SM use and monitoring. The construct of parental knowledge and factors hypothesized to contribute to parental knowledge, including adolescent disclosure, parental solicitation, and parental control, were used to guide the codebook and dyadic data analysis. RESULTS: Dyadic analyses showed that parents and their children disagreed on the use and function of SM in the daily lives of adolescents with depression, with adolescents viewing SM as a forum for honest expression of their emotions, whereas parents felt that their children's posts were inconsequential and interfered with the adolescents' lives. Furthermore, parents reported using a wide range of strategies to gain knowledge of their child's SM use to monitor their safety on SM, including direct solicitation and indirect solicitation, such as keeping the child's passwords, asking friends or siblings about their child's SM use, and restricting SM behavior and access to devices. CONCLUSIONS: Clinicians should support adolescents with depression and their parents in finding common ground for an effective and acceptable monitoring approach. Resources are provided for clinicians navigating conversations about SM use and monitoring with adolescents with depression and their parents during the COVID-19 pandemic.

Social Media Use and Deliberate Self-Harm Among Youth: A Systematized Narrative Review.

BACKGROUND: Suicide is now the 2nd leading cause of death among adolescents and young adults. Social media's influence on youth suicidal risk or attenuation of risk is a novel and rapidly expanding topic of research that requires attention from a broad range of mental health services professionals. We aimed to provide an updated review of social media-related risk and protective factors to youth deliberate-self harm (DSH) to guide mental health services professionals in offering care and support to youth vulnerable to suicide. METHODS: Studies on which primary research was conducted that evaluated young people's use of social media platforms related to DSH were systematically searched via Scopus and identified through expert recommendation and the Association for Computing Machinery's digital library of conference materials. The search focused on the timeframe June 2014 to September 2019, to offer an update since the time the most recent systematic reviews on this topic concluded their literatures searches. Quality was reviewed using the Mixed Methods Appraisal Tool (MMAT). RESULTS: A total of 38 articles were eligible, and 24 articles rated as high quality were included in a narrative review. Of the included articles, 19 explored DSH risk and 8 explored DSH protection. Most articles reported on cross-sectional quantitative or qualitative studies. Opportunities for both risks and benefits were explored, and potential influences of social media use were considered for subgroups of youth who may be especially vulnerable to suicide. CONCLUSIONS: In the relatively short period of review, the association between social media use and youth DSH was tested in population-based studies, offering preliminary evidence for suicide prevention and treatment efforts. Further research is needed to understand the contribution of social media use to youth DSH, particularly among youth most vulnerable to suicidal risk.

Employing Position Generators to Assess Social Capital and Health: A Scoping Review of the Literature and Recommendations in Future Population Health Surveillance.

Beneficial social connections are critical to individual-level health. These connections increase access to social support/resources that can be used to avoid or minimize the risks and consequences associated with diseases. How to best measure beneficial social connections to inform social network-level health interventions remains poorly understood. A scoping review of empirical health research studies was conducted to highlight the utility of employing position generators to assess how access to beneficial social connections was associated with population health and disparities. Our review yielded 39 articles of studies conducted between 2006-2018 across 14 predominantly high-income countries. Most studies (77%) with composite measures for beneficial social connections exhibited health-protective associations. Of the remaining articles, half found that greater diversity within one's network was associated with positive health outcomes. Only eight articles accounted for differences by advantaged statuses, indicating that beneficial connections elicited greater health-protective associations among disadvantaged groups. Employing position generators may inform interventions that seek to reduce health disparities by enhancing social capital in individuals from disadvantaged backgrounds.

Computerized Adaptive Tests for Rapid and Accurate Assessment of Psychopathology Dimensions in Youth.

OBJECTIVE: At least half of youths with mental disorders are unrecognized and untreated. Rapid, accurate assessment of child mental disorders could facilitate identification and referral and potentially reduce the occurrence of functional disability that stems from early-onset mental disorders. METHOD: Computerized adaptive tests (CATs) based on multidimensional item response theory were developed for depression, anxiety, mania/hypomania, attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, and suicidality, based on parent and child ratings of 1,060 items each. In phase 1, CATs were developed from 801 participants. In phase 2, predictive, discriminant, and convergent validity were tested against semi-structured research interviews for diagnoses and suicidality in 497 patients and 104 healthy controls. Overall strength of association was determined by area under the receiver operating characteristic curve (AUC). RESULTS: The child and parent independently completed the Kiddie-Computerized Adaptive Tests (K-CATs) in a median time of 7.56 and 5.03 minutes, respectively, with an average of 7 items per domain. The K-CATs accurately captured the presence of diagnoses (AUCs from 0.83 for generalized anxiety disorder to 0.92 for major depressive disorder) and suicidal ideation (AUC = 0.996). Strong correlations with extant measures were found (r ≥ 0.60). Test-retest reliability averaged r = 0.80. CONCLUSION: These K-CATs provide a new approach to child psychopathology screening and measurement. Testing can be completed by child and parent in less than 8 minutes and yields results that are highly convergent with much more time-consuming structured clinical interviews and dimensional severity assessment and measurement. Testing of the implementation of the K-CAT is now indicated.

Cortisol response to stress as a predictor for suicidal ideation in youth.

OBJECTIVE: To examine the association between cortisol response to stress and suicidal ideation (SI) cross-sectionally and longitudinally in our sample of bereaved and non-bereaved youth. METHODS: The sample included 114 youth bereaved by sudden parental death and 109 non-bereaved controls, mean age of 12.3 (SD = 3.6), evaluated at four time-points over an average follow-up period of 7 years. The Trier Social Stress Test (TSST) was conducted on average 6 years after bereavement. We used latent class analyses to examine the trajectories of SI over follow-up and up to the time of the TSST and compare them on cortisol measures. We examined whether cortisol measures predicted future SI at 18.5 months on average after the TSST. RESULTS: Bereavement was associated with higher cortisol reactivity after controlling for covariates [ß = 0.96, 95% CI (0.28, 1.65), p < 0.01, d = 0.41]. Cortisol reactivity to stress was higher in those belonging to the high SI trajectory [ß = 1.23, 95% CI (0.41, 2.06), p = 0.004, d = 0.23] compared to the low SI trajectory. Higher baseline cortisol showed small to medium effect size in predicting future SI [ß = 2.34, 95% CI (0.17, 4.51), p = 0.03, d = 0.38]. CONCLUSION: The persistence of SI is associated with higher cortisol reactivity to stress, and higher baseline cortisol may predict future SI. These results emphasize the importance of HPA-axis activity in youth exposed to major stressors, and those with SI. More research is needed to further clarify biological mechanisms linking SI and behavior, bereavement, and HPA axis response to stress, to better identify at-risk subjects for targeted prevention and intervention efforts.

Childhood maltreatment, neuropsychological function and suicidal behavior.

BACKGROUND: Suicide is the second leading cause of death in young people. Childhood maltreatment, neuropsychological dysfunction and psychopathology have each been shown to increase risk for suicidal behavior. However, few studies have examined their interactions and the effects of those interactions on suicidal behavior. METHODS: Across two sites, a total of 382 offspring of depressed parents underwent neuropsychological assessments. This high-risk sample included nearly equal numbers of males and females. Average age at the time of neuropsychological assessment was 18.5 years. The most prevalent lifetime psychiatric disorders were mood (43%), anxiety (37%) and alcohol and substance use disorders (21%). Childhood maltreatment was reported by 44% of offspring. Participants underwent extensive neuropsychological testing assessing the following domains: attention, memory, executive function, working memory, language fluency, and impulse control. Logistic regression was used to examine the association of reported childhood maltreatment, neuropsychological functioning, psychopathology and their interactions with suicidal behavior. Bonferroni correction was used to adjust for multiple comparisons. RESULTS: Maltreatment was associated with increased risk of suicidal behavior with odds ratios ranging between 2.40 and 4.43. Moderation analyses found that adaptive neuropsychological functioning was not protective against childhood maltreatment's effect on suicidal risk. While lifetime history of mood disorder was strongly associated with suicidal behavior, higher scores in working memory (OR = 0.21; 95% CI = 0.09, 0.45; p < .001) and executive function (OR = 0.15; 95% CI = 0.05, 0.43; p < .001) were protective against suicidal behavior even in the presence of a lifetime history of mood disorder. CONCLUSIONS: Further research is needed to determine how neuropsychological capacity protects depressed patients against the risk of suicidal behavior.

As Safe as Possible (ASAP): A Brief App-Supported Inpatient Intervention to Prevent Postdischarge Suicidal Behavior in Hospitalized, Suicidal Adolescents.

OBJECTIVE: The authors report on a pilot study of an inpatient intervention for suicidal adolescents, As Safe as Possible (ASAP), supported by a smartphone app (BRITE) to reduce suicide attempts following hospital discharge. METHOD: Across two sites, 66 adolescents hospitalized for suicidal ideation (N=26) or a recent suicide attempt (N=40) were randomly assigned to the ASAP intervention program plus treatment as usual or to treatment as usual alone. ASAP, which focuses on emotion regulation and safety planning, is a 3-hour intervention delivered on the inpatient unit. The BRITE app prompted participants to rate their level of emotional distress on a daily basis and provided personalized strategies for emotion regulation and safety planning. A blind, independent evaluator assessed suicide attempts following hospital discharge and suicidal ideation at 4, 12, and 24 weeks after discharge. RESULTS: The ASAP intervention did not have a statistically significant effect on suicide attempt, although findings were in the hypothesized direction for occurrence of an attempt (16% compared with 31%; χ2=1.86, df=1, g=-0.36) and time to an attempt (hazard ratio=0.49, 95% CI=0.16, 1.47). Past history of a suicide attempt was a significant moderator of treatment outcome, with a stronger, albeit nonsignificant, effect of the ASAP intervention among participants with a history of suicide attempt (hazard ratio=0.23, 95% CI=0.05, 1.09). There were no treatment effects on suicidal ideation. The majority of participants (70%) used the BRITE app (median usage, 19 times). Participants reported high satisfaction with both the intervention and the app. CONCLUSIONS: The ASAP intervention program shows promise in reducing the incidence of postdischarge suicide attempts among adolescents hospitalized for suicidality and merits further study.

The Burden of Bereavement: Early-Onset Depression and Impairment in Youths Bereaved by Sudden Parental Death in a 7-Year Prospective Study.

OBJECTIVE: The authors sought to determine the long-term impact of sudden parental death on youths and pathways between youth bereavement and impairment. METHODS: Youths (N=216) who lost a parent to suicide, accident, or sudden natural death and nonbereaved youths (N=172) were followed periodically for up to 7 years. The incidence and prevalence of disorder and of functional impairment, as well as pathways to impairment, were assessed using Cox and mixed-effects logistic regression and structural equation modeling. RESULTS: Prior to parental death, bereaved youths had higher rates of psychiatric disorder, parental psychiatric disorder, and maltreatment. Even after adjustment for predeath risk factors, bereavement was associated with an increased incidence of depression, posttraumatic stress disorder, and functional impairment. The peak incidence of depression was in the first 2 years postbereavement, with incident depression occurring mainly in those who lost a parent at age 12 or younger. Youths bereaved by all three causes of death showed higher rates of impairment at all time points. Structural equation modeling found that bereavement had a direct effect on impairment and was also linked to impairment via its effects on early and later depression and through negative life events. Child psychiatric disorder prior to parental loss also contributed to functional impairment. CONCLUSIONS: Parental death increased the incidence of depression in offspring early in the course of bereavement. Early identification and treatment of depression in bereaved youths and augmentation of family resilience may protect against later sequelae of functional impairment.

Developing a Brief Suicide Prevention Intervention and Mobile Phone Application: a Qualitative Report.

Suicide is the second leading cause of death among youth and has become a serious public health problem. There has been limited research on strategies to decrease the likelihood of reattempt in adolescents. As phase one of a treatment development study, clinicians, parents and adolescents participated in qualitative interviews in order to gain new perspectives on developing a targeted intervention and a safety plan phone application for suicide prevention. Participants indicated that transition of care, specific treatment targets and safety planning were important parts of treatment. In addition, all participants endorsed the use of a smartphone application for these purposes.

Familial pathways to early-onset suicide attempt: a 5.6-year prospective study.

IMPORTANCE: Suicide attempts are strong predictors of suicide, a leading cause of adolescent mortality. Suicide attempts are highly familial, although the mechanisms of familial transmission are not understood. Better delineation of these mechanisms could help frame potential targets for prevention. OBJECTIVE: To examine the mechanisms and pathways by which suicidal behavior is transmitted from parent to child. DESIGN, SETTING, AND PARTICIPANTS: In this prospective study conducted from July 15, 1997, through June 21, 2012, a total of 701 offspring aged 10 to 50 years (mean age, 17.7 years) of 334 clinically referred probands with mood disorders, 191 (57.2%) of whom had also made a suicide attempt, were followed up for a mean of 5.6 years. MAIN OUTCOMES AND MEASURES: The primary outcome was a suicide attempt. Variables were examined at baseline, intermediate time points, and the time point proximal to the attempt. Participants were assessed by structured psychiatric assessments and self-report and by interview measures of domains hypothesized to be related to familial transmission (eg, mood disorder and impulsive aggression). RESULTS: Among the 701 offspring, 44 (6.3%) had made a suicide attempt before participating in the study, and 29 (4.1%) made an attempt during study follow-up. Multivariate logistic regression revealed that proband suicide attempt was a predictor of offspring suicide attempt (odds ratio [OR], 4.79; 95% CI, 1.75-13.07), even controlling for other salient offspring variables: baseline history of mood disorder (OR, 4.20; 95% CI, 1.37-12.86), baseline history of suicide attempt (OR, 5.69; 95% CI, 1.94-16.74), and mood disorder at the time point before the attempt (OR, 11.32; 95% CI, 2.29-56.00). Path analyses were consistent with these findings, revealing a direct effect of proband attempt on offspring suicide attempt, a strong effect of offspring mood disorder at each time point, and impulsive aggression as a precursor of mood disorder. CONCLUSIONS AND RELEVANCE: Parental history of a suicide attempt conveys a nearly 5-fold increased odds of suicide attempt in offspring at risk for mood disorder, even after adjusting for the familial transmission of mood disorder. Interventions that target mood disorder and impulsive aggression in high-risk offspring may attenuate the familial transmission of suicidal behavior.