Abstract
Background:
Suicidal thoughts and behaviors (STBs) became more common among racial and ethnic minorities and sexual and gender minorities (SGM) during the COVID-19 pandemic relative to White and non-SGM adolescents. This study examines associations between pandemic-related stressors and STBs among a nationally representative sample of adolescents to identify vulnerable subpopulations.
Methods:
We analyzed data from 6,769 high school students using the 2021 Adolescent Behaviors and Experiences Survey. Pandemic-related stressors were assessed via seven items related to negative experiences (e.g., parent job loss; food insecurity) during the COVID-19 pandemic. Logistic regression analyses estimated the association between pandemic-related stressors and four outcomes: (1) sadness/hopelessness; (2) suicidal ideation; (3) suicide planning; and (4) recent suicide attempt (i.e., past 12 months). Interactions were modeled by sex, race/ethnicity, and sexual identity.
Results:
A greater number of pandemic-related stressors was associated with higher odds for sadness and hopelessness (aOR: 1.55; 95% CI:1.44 – 1.67), suicidal ideation (aOR: 1.48; 95% CI:1.39 – 1.57), suicide planning (aOR:1.47; 95% CI: 1.36 – 1.59), and recent suicide attempt (aOR: 1.64; 95% CI:1.42 – 1.88). Pandemic-related stressors were also more strongly associated with some types of STBs in males (relative to females) and SGM females (relative to heterosexual females).
Conclusion:
Study findings indicate that pandemic-related stressors are associated with STBs within the US adolescent population, particularly among male and SGM female adolescents. Researchers are encouraged to use this knowledge to ensure nationwide suicide prevention efforts adequately address inequities in suicide risk.
Keywords: suicide, adolescents, COVID-19, pandemic, equity, minority, stressors
INTRODUCTION
Suicide is the second leading cause of adolescent deaths in the US.1 Further, the suicide rate for adolescents who identify as racial and ethnic minorities and sexual and gender minorities (SGM) is increasing rapidly,2–4 and it’s becoming alarmingly more common for these adolescents to seriously consider, plan, and attempt suicide.5–7 For example, in 2021, Black adolescents (15.2%) had a higher prevalence reporting a suicide attempt in the past year compared with Asian (8.4%), Hispanic (11.9%), and White (12.4%) adolescents, and the prevalence of past-year suicide attempts was higher in lesbian or gay (15.2%) and bisexual adolescents (26.5%) than heterosexual adolescents (8.1%).5 There is a nationwide effort to reduce the annual rate of suicide in the United States by 20% by 2025 (https://project2025.afsp.org/), but equitably achieving this goal will require proper identification and understanding of the risk factors for suicide within both the general population, as well as vulnerable and underserved populations.
Suicidal thoughts and behavior (STB) is an important risk factor for suicide,8,9 and several factors are associated with the development of STBs, including childhood adversity and social isolation.8 These factors were all intensified by the COVID-19 pandemic.10 During the pandemic, adolescents experienced significant adversity and isolation that disrupted their lives. For example, 55% of adolescents reported emotional abuse by a parent or other adult in their home, and 24% reported significant amounts of hunger.11 Unfortunately, data collected during the Coronavirus (COVID-19) pandemic suggested that almost 20% of adolescents considered and 10% attempted suicide in the past 12 months,10 and other studies have also shown that suicide among adolescents, including intentional and unintentional drug overdoses,12,13 were substantially higher during the pandemic than before.14,15
Current research seldom explores sub-population variation in adolescent STBs because it requires large sample sizes. However, the evidence is clear that adolescents who identified as female, racial/ethnic minority, or SGM experienced more adversity and social disruptions during the pandemic (e.g., emotional and physical abuse) than their peers.11 Further, the prevalence of STBs is now higher among these same groups compared with their counterparts.5–7 However, no evidence is available to support whether pandemic-related stressors (i.e., adversity and social disruptions reported during the pandemic) impacted STBs differently among racial and ethnic minorities and SGM adolescents compared with Whites and non-SGM adolescents. Identifying and examining group differences in STBs based on the degree of exposure to pandemic-related stressors may improve suicide prevention, diagnosis, and treatment across diverse groups as the US continues to address mental health challenges related to the COVID-19 pandemic.
Thus, this study examines the association of pandemic-related stressors (i.e., adversity and social disruptions reported during the pandemic) with STBs among a nationally representative sample of adolescents.16 We assess four self-reported STB outcomes: (1) feelings of sadness/hopelessness, (2) suicidal ideation, (3) planned suicide attempt, and (4) any suicide attempt in the past 12 months. The primary hypothesis is that the odds of all STB outcomes will increase as the number of pandemic-related stressors increases. Descriptively, this study also identifies subgroups, such as racial/ethnic minorities and SGM adolescents, that may be particularly vulnerable to STBs based on the degree of adversity and social disruptions experienced during the pandemic. Analytically, this study examines the possible modifying effect of sex, race/ethnicity, and sexual identity on the association of pandemic-related stressors with STBs. We hypothesize that the association of pandemic-related stressors with STBs will be significantly modified by sex, race/ethnicity, and sexual identity, with pandemic-related stressors more strongly associated with STBs among females (relative to males), racial/ethnic minorities (relative to non-Hispanic Whites), and sexual minorities (relative to heterosexuals).
METHODS
This study analyzes data from the CDC’s 2021 Adolescent Behaviors and Experiences Survey (ABES),16 a cross-sectional study of 9th-12th-grade students attending public or private high schools in the US. The ABES data were collected using a stratified, three-stage cluster probability-based sampling approach to obtain a nationally representative sample of high school students. All data were collected via self-reported measures collected through a digital survey. Data were collected during Spring 2021 (January – June). ABES’s methodology, protocol, and survey instrument mirror the Youth Risk Behavioral Surveillance Survey (YRBSS).17 Details about ABES’s study design, sampling, and procedures can be found elsewhere.16 This study is exempt from ethical compliance because it uses a publicly available anonymized database.
Study Sample & Missing Data
There were 7,705 adolescents in the ABES dataset, and we conducted a complete case analysis (CCA) on two analytic samples. The first sample was 6,795 adolescents with complete data on study variables. Second, we created a subsample to compute descriptive and analytic figures for one study outcome (suicide attempt: yes/no) with disproportionate missingness. Specifically, 720 adolescents had missing data for suicide attempts, resulting in a CCA of 6,075 adolescents who completed ABES in 2021. Missingness in the ABES dataset reflects missing not at random (MNAR) because school administrators can modify the survey for the ABES (and YRBSS) datasets, including removing questions.16,18
Measures
Suicidal thoughts and behaviors (STBs).
We examined four risk factors of suicide. Adolescents were asked to report their experiences within the past 12 months: (Q1) “did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?” (i.e., feelings of sadness/hopelessness); (Q2) “did you ever seriously consider attempting suicide?” (i.e., suicidal ideation); (Q3) “did you make a plan about how you would attempt suicide?” (i.e., suicide planning); and (Q4) “how many times did you attempt suicide?” (i.e., suicide attempt). Possible responses for Q1 – Q3 were “yes” and “no.” This binary coding was retained for analysis. Similar to other studies using ABES data, responses for Q4 were recoded to reflect 0 suicide attempts (referent) and one or more suicide attempts.10
Pandemic-related stressors.
The primary independent variable of this study was the count of stressors experienced during the pandemic. Pandemic-related stressors asked via ABES reflected the following constructs with corresponding question numbers as listed in the CDC methodological guide of the ABES dataset: (a) parental job loss (Q101), (b) self-job loss (Q102), (c) food insecurity (Q103), (d) schoolwork difficulty (Q104), (e) emotional abuse from parents/guardians (Q105), (f) parental physical abuse during pandemic (Q106), and (g) virtual connectedness during pandemic (Q111). Each of these items was dichotomized, per CDC recommendations, and used to generate a composite number of stressors experienced due to the pandemic. To account for outliers and data skewness, we combined responses of experiencing 5 through 7 stressors.
Demographics.
Per the federal standard, race and ethnicity were categorized into four mutually exclusive categories: (1) non-Hispanic White (referent), (2) Hispanic or Latino, (3) non-Hispanic African American/Black, (4) non-Hispanic Other, which was comprised of Asians, multiple racial identities, and American Indian/Alaskan Native/Other Pacific Islander. These categories were selected in order to be consistent with the Federal Interagency Technical Working Group on Race and Ethnicity Standard for revising the Office of Management and Budget (OMB) 1997 Statistical Policy Directive No. 15: Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity.19 Sex assigned at birth was examined, with males serving as the referent group. Sexual identity was categorized as (1) heterosexual (referent), (2) gay or lesbian, (3) bisexual, and (4) questioning/other. Participants who reported, “I do not know what this question is asking,” were excluded (n = 153).
Covariates.
Grade level was coded ordinally from ninth (referent) through 12th grade. Other covariates included (a) cyberbullying victimization, 20,21 (b) discrimination,22,23 and (c) current (past 30-day) tobacco use.24,25 There is sufficient evidence that these factors are associated with an increased risk of suicidal thoughts and behaviors.8 First, participants were asked: “During the past 12 months, have you ever been electronically bullied? (Count being bullied through texting, Instagram, Facebook, or other social media.)” Possible responses were “no” and “yes.” We elected to use cyberbullying victimization as nearly half of the population reported attending school “virtual-only” (24.4%) or a combination of virtual and in-person (hybrid; 22.3%).16 Racial discrimination was assessed by asking participants, “During your life, how often have you felt that you were treated badly or unfairly in school because of your race or ethnicity? Responses were dichotomized into: “no” (Never) and “yes” (Rarely or more). Current tobacco use reflected the use of one or more of the following products: (a) combustible cigarettes, (b) combustible cigars/cigarillos, (c) electronic cigarettes, and (d) smokeless tobacco products. Participants who reported using one or more of these products in the past 30 days were considered current tobacco users.
Statistical Analyses
Weighted frequencies for each variable are reported, and bivariate associations are estimated and reported in Table 1. Descriptive statistics are presented for the total sample of pandemic-related stressors and STBs. We reported these weighted frequencies as percentages and corresponding 95% confidence intervals. Next, multivariable logistic regression models were conducted to evaluate the study hypotheses. First, we conducted four regression models to examine the association of experiencing pandemic-related stressors with (1) feelings of sadness/hopelessness, (2) suicidal ideation, (3) planned suicide attempts, and (4) suicide attempts in the past 12 months. These analyses controlled for sex, race/ethnicity, grade, sexual identity, cyberbullying, discrimination, and current tobacco use. These regressions modeled pandemic-related stressors as a continuous variable (0 – 5+), producing a single effect (adjusted odds ratio [aOR]) and p-value for each regression.
Table 1:
Percentage of US high school students who reported persistent feelings of sadness or hopelessness, suicidal ideation and attempts, and the average amount of self-reported pandemic-related stressors, by sociodemographic characteristics — 2021 Adolescent Behaviors and Experiences Survey
| Full Sample (n=6,795) | Sad/Hopelessa | Suicidal Ideationb | Planned Suicide Attemptc | Recent Suicide Attemptd | Pandemic-related Stressors | |
|---|---|---|---|---|---|---|
| % Yes | % Yes | % Yes | % Yes | M (SD) | ||
| Full Sample | -- | 44.5 (41.9 – 47.2) | 20.5 (18.5 – 22.6) | 15.6 (13.8 – 17.5) | 8.5 (7.3 – 9.9) | 2.19 (1.32) |
| Sex | ||||||
| Male | 48.9% (45.2 – 52.6) | 31.6 (29.4 – 33.9) | 14.2 (12.4 – 16.3) | 10.2 (8.9 – 11.8) | 5.0 (3.9 – 6.3) | 2.02 (1.28) |
| Female | 51.1% (47.4 – 54.8) | 56.9 (53.7 – 60.0) | 26.5 (23.9 – 29.1) | 20.7 (18.3 – 23.4) | 11.9 (10.2 – 13.9) | 2.35 (1.35) |
| Racial/Ethnic Identity e | ||||||
| Non-Hispanic White | 51.0% (42.7 – 59.3) | 43.6 (40.0 – 47.2) | 21.2 (18.7 – 24.0) | 15.6 (13.2 – 18.4) | 8.2 (6.5 – 10.3) | 2.06 (1.24) |
| Hispanic/Latino | 25.1% (19.7 – 31.4) | 46.5 (41.9 – 51.2) | 20.1 (17.3 – 23.2) | 15.9 (13.8 – 18.1) | 8.1 (6.4 – 10.3) | 2.35 (1.37) |
| Non-Hispanic, Black | 11.9% (8.7 – 16.3) | 42.4 (38.1 – 46.7) | 17.1 (13.6 – 21.3) | 12.9 (9.8 – 16.9) | 9.7 (7.6 – 12.4) | 2.26 (1.46) |
| Non-Hispanic Other | 11.9% (8.2 – 17.0) | 46.6 (42.4 – 50.9) | 21.5 (16.9 – 26.9) | 17.5 (13.4 – 22.7) | 9.7 (7.0 – 13.3) | 2.32 (1.37) |
| Grade Level | ||||||
| 9th Grade | 26.8% (24.1 – 29.7) | 43.5 (38.8 – 48.3) | 22.2 (18.1 – 26.8) | 15.8 (12.8 – 19.2) | 10.2 (7.8 – 13.4) | 2.18 (1.36) |
| 10th Grade | 24.9% (22.9 – 26.9) | 44.1 (40.1 – 48.2) | 20.2 (17.3 – 23.4) | 16.0 (13.6 – 18.8) | 8.9 (7.0 – 11.2) | 2.16 (1.30) |
| 11th Grade | 24.3% (22.5 – 26.3) | 46.1 (41.8 – 50.5) | 20.1 (17.3 – 23.2) | 16.0 (13.0 – 19.5) | 8.5 (6.4 – 11.0) | 2.17 (1.33) |
| 12th Grade | 24.0% (21.7 – 26.4) | 44.5 (40.6 – 48.5) | 19.3 (16.1 – 22.9) | 14.5 (11.1 – 18.8) | 6.3 (4.3 – 9.3) | 2.25 (1.29) |
| Sexual Identity f | ||||||
| Heterosexual | 77.9% (75.9 – 79.8) | 36.7 (34.0 – 39.4) | 13.8 (11.9 – 16.0) | 10.0 (8.3 – 12.0) | 4.9 (3.8 – 6.3) | 2.06 (1.30) |
| Gay/Lesbian | 3.0% (2.4 – 3.8) | 70.0 (61.4 – 77.0) | 40.1 (30.9 – 50.1) | 30.8 (24.0 – 38.5) | 20.7 (15.1 – 27.6) | 2.54 (1.22) |
| Bisexual | 9.9% (8.9 – 11.1) | 76.7 (70.9 – 81.6) | 49.8 (43.3 – 56.3) | 40.2 (35.2 – 45.3) | 26.8 (21.9 – 32.3) | 2.78 (1.39) |
| Questioning/Other | 9.1% (8.2 – 10.2) | 68.1 (62.4 – 73.4) | 38.9 (33.7 – 44.4) | 31.7 (26.7 – 37.2) | 14.9 (10.2 – 21.2) | 2.54 (1.27) |
| Discrimination g | ||||||
| No | 65.0% (61.3 – 68.5) | 37.4 (34.1 – 40.9) | 16.5 (14.5 – 18.7) | 12.1 (10.2 – 14.1) | 6.0 (4.8 – 7.5) | 1.94 (1.24) |
| Yes | 35.0% (31.5 – 38.7) | 57.7 (54.4 – 60.9) | 27.8 (24.8 – 31.1) | 22.2 (19.3 – 25.4) | 13.3 (11.1 – 15.9) | 2.66 (1.35) |
| Tobacco Use h | ||||||
| No | 84.4% (81.9 – 86.7) | 40.3 (37.7 – 42.9) | 16.9 (15.1 – 18.9) | 12.8 (11.3 – 14.6) | 6.1 (5.2 – 7.0) | 2.08 (1.29) |
| Yes | 15.6% (13.3 – 18.1) | 67.4 (63.2 – 71.4) | 39.9 (36.3 – 43.6) | 30.5 (27.1 – 34.2) | 22.5 (18.3 – 27.3) | 2.77 (1.33) |
| Cyber Bullying i | ||||||
| No | 86.2% (84.7 – 87.6) | 40.1 (37.5 – 42.7) | 17.0 (15.3 – 18.8) | 12.1 (10.7 – 13.7) | 6.2 (5.2 – 7.3) | 2.08 (1.29) |
| Yes | 13.8% (12.4 – 15.3) | 72.5 (68.6 – 76.2) | 42.5 (38.5 – 46.6) | 37.2 (32.9 – 41.7) | 23.6 (19.7 – 28.0) | 2.90 (1.31) |
| Pandemic-related Stressors | 2.19 (1.32) | No: 1.77 (1.20) | No: 2.0 (1.26) | No: 2.04 (1.26) | No: 2.07 (1.26) | -- |
| Yes: 2.71 (1.28) | Yes: 2.94 (131) | Yes: 3.03 (1.32) | Yes: 3.30 (1.29) |
Self-reported response (yes/no) to “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?”
Self-reported response to (yes/no) “During the past 12 months, did you ever seriously consider attempting suicide?”
Self-reported response to (yes/no) “During the past 12 months, did you make a plan about how you would attempt suicide?”
Recoded self-reported response to (yes [includes 1, 2–3, 4–5, ≥6 times]/no [includes 0]) “During the past 12 months, how many times did you actually attempt suicide?”
Additionally, we test for possible effect modification using interactions and stratification by demographic variables.26 We conducted three iterations of multivariable logistic regression models fitted with a two-way interaction term between the pandemic-related stressors variable and (1) sex, (2) race/ethnicity, and (3) sexual identity. Next, we conducted stratified analyses for statistically significant interactions (p<0.05). Then, among the stratified samples, we fitted a two-way interaction term between pandemic-related stressors and the other two demographic variables. For example, a statistically significant interaction between pandemic-related stressors and sex (Model 1) would result in stratified analyses of pandemic-related stressors and STBs among males and females (Model 2), followed by fitting the interaction term of pandemic-related stressors and race/ethnicity (Model 3) as well as an interaction term of pandemic-related stressors and sexual identity (Model 4), each stratified by sex. This sequential methodology allowed us to quantitatively explore the impact of pandemic-related stressors and STBs among various subgroups of adolescents. Analyses were conducted in Stata 17 (College Station, TX).
RESULTS
Sample characteristics
Approximately 44.5% of adolescents reported sadness and hopelessness, 20.5% reported suicidal ideation, 15.6% reported suicide planning, and 8.5% reported a suicide attempt in the past 12 months. Adolescents reported experiencing 2.19 (SD = 1.32) pandemic-related stressors on average. Exactly 9.3% of adolescents report experiencing no pandemic-related stressors, 23.8% reported one, 28.2% reported two, 21.8% reported three, 11.1% reported four, and 5.8% reported five or more pandemic-related stressors. Additional characteristics of the study sample can be found in Table 1.
Pandemic-Related Stressors and STBs among Adolescents
As shown in Table 2, each unit increase in pandemic-related stressors was associated with increased odds of reporting sadness and hopelessness (aOR: 1.55; 95% CI: 1.44 – 1.67), suicidal ideation (aOR: 1.48; 95% CI: 1.39 – 1.57), suicide planning (aOR: 1.47; 95% CI: 1.36 – 1.59), and suicide attempt in the past 12-months (aOR: 1.64; 95% CI: 1.42 – 1.88), controlling for sex, race/ethnicity, grade, sexual identity, cyberbullying, perceived racial/ethnic discrimination, and past 30-day tobacco use.
Table 2.
Association of pandemic-related stressors with suicidal thoughts and behaviors among US high school students — 2021 Adolescent Behaviors and Experiences Survey.
| Sad/Hopelessa (n=6,795) |
Ideationb (n=6,758) |
Planned Attemptc (n=6,758) |
Suicide Attemptd (P12M) (n=6,758) |
|
|---|---|---|---|---|
| Odds Ratio 95% Confidence Interval |
Odds Ratio 95% Confidence Interval |
Odds Ratio 95% Confidence Interval |
Odds Ratio 95% Confidence Interval |
|
| Pandemic-related stressors (min = 0, max=5) | 1.55 (1.44 – 1.67)* | 1.48 (1.39 – 1.57)* | 1.47 (1.36 – 1.59)* | 1.64 (1.42 – 1.88)* |
| Sex | ||||
| Male | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Female | 2.21 (1.89 – 2.55)* | 1.22 (1.03 – 1.45)* | 1.23 (0.98 – 1.55) | 1.23 (0.90 – 1.67) |
| Racial/Ethnic Identity | ||||
| Non-Hispanic White | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Hispanic/Latino | 1.14 (0.91 – 1.42) | 0.96 (0.77 – 1.19) | 1.07 (0.81 – 1.40) | 1.19 (0.83 – 1.69) |
| Non-Hispanic, Black | 0.98 (0.80 – 1.21) | 0.82 (0.59 – 1.12) | 0.91 (0.66 – 1.25) | 1.60 (1.09 – 2.36)* |
| Non-Hispanic Otherb | 1.07 (0.86 – 1.33) | 0.95 (0.72 – 1.25) | 1.09 (0.73 – 1.65) | 1.15 (0.72 – 1.85) |
| Grade Level | ||||
| 9th Grade | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| 10th Grade | 1.08 (0.86 – 1.36) | 0.87 (0.62 – 1.22) | 1.10 (0.79 – 1.54) | 0.91 (0.59 – 1.42) |
| 11th Grade | 1.10 (0.87 – 1.38) | 0.82 (0.58 – 1.15) | 1.02 (0.72 – 1.44) | 0.72 (0.46 – 1.12) |
| 12th Grade | 0.96 (0.75 – 1.21) | 0.74 (0.57 – 0.97) | 0.92 (0.69 – 1.23) | 0.58 (0.36 −0.93)* |
| Sexual Identity c | ||||
| Heterosexual | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Gay/Lesbian | 3.17 (1.88 – 5.33)* | 3.36 (2.03 – 5.54)* | 3.07 (2.05 – 4.59)* | 4.02 (2.51 – 6.44)* |
| Bisexual | 3.14 (2.25 – 4.38)* | 4.11 (2.84 – 5.95)* | 3.67 (2.56 – 5.27)* | 4.12 (2.66 – 6.38)* |
| Questioning/Other | 1.99 (1.57 – 2.52)* | 2.61 (2.02 – 3.39)* | 2.76 (2.13 – 3.59)* | 2.54 (1.66 – 3.91)* |
| Discrimination g | ||||
| 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | |
| 2.84 (2.12 – 3.81)* | 2.43 (1.86 – 3.18)* | 2.68 (2.04 – 3.51)* | 2.81 (2.04 – 3.89)* | |
| Tobacco Use (P30D) | ||||
| No | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Yes | 2.25 (1.81 – 2.79)* | 2.28 (1.80 – 2.89)* | 1.94 (1.52 – 2.49)* | 3.27 (2.33 – 4.59)* |
| Cyber Bullying | ||||
| No | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Yes | 2.10 (1.60 – 2.76)* | 1.75 (1.48 – 2.08)* | 2.11 (1.70 – 2.62)* | 1.98 (1.41 – 2.77)* |
p < 0.05
Self-reported response (yes/no) to “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?”
Self-reported response to (yes/no) “During the past 12 months, did you ever seriously consider attempting suicide?”
Self-reported response to (yes/no) “During the past 12 months, did you make a plan about how you would attempt suicide?”
Recoded self-reported response to (yes [includes 1, 2–3, 4–5, ≥6 times]/no [includes 0]) “During the past 12 months, how many times did you actually attempt suicide?”
Interactions and Stratified Analyses
There was no statistically significant interaction between pandemic-related stressors and sex in the association with sadness/hopelessness (aOR: 1.03; 95% CI: 0.92 – 1.15), suicidal ideation (aOR: 0.95; 95% CI: 0.83 – 1.10), or planned suicide attempts (aOR: 0.89; 95% CI: 0.77 – 1.03). There was a statistically significant interaction between pandemic-related stressors and sex in the association with suicide attempts in the past 12 months (aOR: 0.73; 95% CI: 0.55 – 0.97). As a result, we modeled the association between pandemic-related stressors and suicide attempts, stratified by sex. As shown in Table 3 (Model 2), each unit increase in pandemic-related stressors was associated with increased odds of a planned suicide attempt by 2.08 (95% CI: 1.58 – 2.74) times among males, compared with 1.54 (95% CI: 1.36 – 1.74) times among females, controlling for covariates. Thus, the association between pandemic-related stressors and suicide attempts was approximately 35.1% stronger in males than females.
Table 3:
Association of pandemic related-stressors with suicidal thoughts and behaviors among US high school students: Interaction and effect modification by sex, race/ethnicity, and sexual identity; Covariates and model specifications listed below
| Sad/Hopelessa | Suicidal Ideationb | Planned Suicide Attemptc | Recent Suicide Attemptd | |
|---|---|---|---|---|
| Odds Ratio 95% Confidence Interval |
Odds Ratio 95% Confidence Interval |
Odds Ratio 95% Confidence Interval |
Odds Ratio 95% Confidence Interval |
|
| Model 1: Interaction of Pandemic-Related Stressors & Sex | ||||
| Pandemic-related stressors | ||||
| 0–5+ Stressors | 1.53 (1.39 – 1.68)* | 1.52 (1.40 – 1.66)* | 1.59 (1.43 – 1.77)* | 2.11 (1.60 – 2.78)* |
| Sex | ||||
| Male | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Female | 2.08 (1.56 – 2.78)* | 1.56 (1.06 – 2.29)* | 1.92 (1.17 – 3.13)* | 3.88 (1.49 – 10.11)* |
| Pandemic-related stressors * Sex | ||||
| Interaction | 1.03 (0.92 – 1.15) | 0.95 (0.83 – 1.10) | 0.89 (0.77 – 1.03) | 0.73 (0.55 – 0.97)* |
| Model 2: Main Effect, Stratified by Sex | ||||
| Males (n=3,319) | ||||
| Pandemic-related stressors | ||||
| 0–5+ Stressors | 1.55 (1.41 – 1.70)* | 1.51 (1.37 – 1.66)* | 1.56 (1.39 – 1.74)* | 2.08 (1.58 – 2.74)* |
| Females (n=3,699) | ||||
| Pandemic-related stressors | ||||
| 0–5+ Stressors | 1.55 (1.43 – 1.68)* | 1.44 (1.31 – 1.59)* | 1.37 (1.24 – 1.52)* | 1.54 (1.36 – 1.74)* |
| Model 3: Interaction of Pandemic-Related Stressors & Racial/Ethnic Identity (R/E), Stratified by Sex | ||||
| Males (n=3,319) | ||||
| Pandemic-related stressors * R/E | ||||
| Non-Hispanic White | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Hispanic/Latino | 0.80 (0.68 – 0.95) | 0.74 (0.60 – 0.91)* | 0.84 (0.66 – 1.07) | 0.62 (0.37 – 1.04) |
| Non-Hispanic, Black | 0.84 (0.61 – 1.16) | 0.69 (0.43 – 1.11) | 0.96 (0.61 – 1.52) | 0.96 (0.52 – 1.77) |
| Non-Hispanic Other | 1.02 (0.79 – 1.31) | 0.94 (0.68 – 1.30) | 0.83 (0.54 – 1.27) | 1.01 (0.57 – 1.81) |
| Females (n=3,699) | ||||
| Pandemic-related stressors * R/E | ||||
| Non-Hispanic White | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Hispanic/Latino | 1.00 (0.84 – 1.20) | 1.01 (0.77 – 1.33) | 0.91 (0.73 – 1.13) | 0.83 (0.63 – 1.10) |
| Non-Hispanic, Black | 0.98 (0.79 – 1.21) | 0.96 (075 – 1.23) | 0.91 (0.66 – 1.25) | 0.79 (0.55 – 1.13) |
| Non-Hispanic Othere | 1.06 (0.85 – 1.32) | 0.96 (0.68 – 1.36) | 0.61 (0.42 – 0.89)* | 0.79 (0.49 – 1.28) |
| Model 4: Interaction of Pandemic-Related Stressors & Sexual Identity (SI), Stratified by Sex | ||||
| Males (n=3,319) | ||||
| Pandemic-related stressors * SI | ||||
| Heterosexual | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Gay/Lesbian | 2.93 (0.60 – 14.26) | 0.86 (0.52 – 1.78) | 0.96 (0.58 – 1.58) | 1.06 (0.48 – 2.31) |
| Bisexual | 6.75 (2.12 – 21.54)* | 1.01 (0.65 – 1.56) | 0.90 (0.57 – 1.42) | 1.35 (0.66 – 2.79) |
| Questioning/Other | 1.68 (0.77 – 3.70) | 0.85 (0.63 – 1.16) | 0.86 (0.61 – 1.21) | 1.83 (0.86 – 3.91) |
| Females (n=3,699) | ||||
| Pandemic-related stressors * SI | ||||
| Heterosexual | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Gay/Lesbian | 1.10 (0.59 – 2.01) | 1.76 (0.38 – 8.11) | 2.40 (0.57 – 10.12) | 0.89 (0.52 – 1.53) |
| Bisexual | 1.31 (0.96 – 1.79) | 3.24 (1.58 – 6.65)* | 3.17 (1.13 – 8.94)* | 1.06 (0.79 – 1.42) |
| Questioning/Other | 1.26 (1.01 – 1.57)* | 1.15 (1.01 – 3.59) | 1.15 (0.87 – 1.50) | 0.94 (0.68 – 1.30) |
p < 0.05
Note: All models control for grade level, sex, race/ethnicity, sexual identity, cyberbullying, racial discrimination, and current tobacco use
Self-reported response (yes/no) to “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?”
Self-reported response to (yes/no) “During the past 12 months, did you ever seriously consider attempting suicide?”
Self-reported response to (yes/no) “During the past 12 months, did you make a plan about how you would attempt suicide?”
Recoded self-reported response to (yes [includes 1, 2–3, 4–5, ≥6 times]/no [includes 0]) “During the past 12 months, how many times did you actually attempt suicide?”
Sex-stratified models testing the interaction between pandemic-related stressors and race/ethnicity (Model 3) or sexual identity (Model 4) among males and females are presented in Table 3. There was no consistent evidence that pandemic-related stressors were associated with significantly different STBs for males and females of different racial and ethnic identities. Similarly, there was minimal significance in the interaction between sexual identity and pandemic-related stressors, stratified by sex, as only 4 of the 24 comparisons made were statistically significant. However, among males, there was a significant interaction between bisexual identity (relative to heterosexual) and pandemic-related stressors for feelings of sadness and hopelessness (aOR: 6.75, 95% CI: 2.12 – 21.54). Similarly, among females, there was a significant interaction between questioning identity (relative to heterosexual) and pandemic-related stressors for feelings of sadness and hopelessness (aOR: 1.26, 95% CI: 1.01 – 1.57) as well as bisexual identity (relative to heterosexual) for suicidal ideation (aOR: 3.24, 95% CI: 1.58 – 6.65) and planned suicide attempt (aOR:3.17, 95% CI: 1.13, 8.94) in the past 12 months.
There were no statistically significant interactions between pandemic-related stressors and race/ethnicity in sadness and hopelessness, suicidal ideation, or suicide attempt. Similarly, there were no statistically significant interactions between pandemic-related stressors and sexual identity in depression, suicidal ideation, or suicide attempts with heterosexual adolescents as the referent category. These interactions and stratified analyses are presented in supplemental materials.
DISCUSSION
This study examined the association of pandemic-related stressors with STBs using a representative sample of US adolescents by self-reported sex, race/ethnicity, and SGM identity. Study findings supported the central hypothesis; overall, reporting more pandemic-related stressors was associated with increased odds of all adolescent STB outcomes. Furthermore, our study results indicated that these associations varied by some sociodemographic characteristics. First, the association between pandemic-related stressors and suicide attempts was approximately 35.1% stronger in males than females. Conversely, the association of pandemic-related stressors with STBs was similar across racial and ethnic groups and sexual minority identities. However, when the data were stratified by sex, female adolescents who identified as a sexual minority (i.e., Bisexual and Questioning/Other Identity) and reported more pandemic-related stressors also had higher odds for STBs than their heterosexual counterparts. Likewise, male adolescents who identified as bisexual and reported more pandemic-related stressors also had higher odds of sadness and hopelessness than their heterosexual counterparts. Overall, these study findings highlight the negative impact of pandemic-related stressors on STBs within the US adolescent population, particularly among male and female adolescents who identify as a sexual minority.
Study findings align with recent studies indicating that pandemic-related adversity and social disruptions have significantly affected poor mental health, including suicide and STBs, among adolescents.10,11 We further contribute to the literature by highlighting subgroups who may be struggling to cope with adversity and social disruptions during the pandemic. For instance, although pandemic-related stressors were associated with suicide attempts in the past 12 months in both females and males, the association was stronger in males. Adolescent males are typically taught to be self-reliant due to societal norms surrounding masculinity.27 As such, male adolescents may be less likely to seek mental health services in the school or community or talk with family, friends, and loved ones about their challenges and struggles.28,29 Further, unlike female adolescents, male adolescents display early warnings of suicide by engaging in acts of aggression, delinquency, and antisocial behavior.30 Family members and loved ones may not recognize these externalizing behaviors as early warning signs of suicide in male adolescents.31 These behaviors, if left untreated, may escalate into self-harm.32 Overall, it is critical that future research deeply explore male vulnerability to STBs during the pandemic, given that evidence shows that life expectancy is worse for adolescent males who attempt suicide than for adolescent females.33,34
Study findings showed that sexual minority adolescents, particularly those who identified as bisexual, questioning, or another sexual identity, had increased vulnerability to STBs as exposure to pandemic-related stressors increased. These findings align with previous studies showing that SGM adolescents have experienced disproportionate exposure to pandemic-related stressors and greater vulnerability to poor mental health and STBs than their non-SGM counterparts.35,36 The lack of social and family acceptance of SGM adolescents may be the primary explanation for heightened vulnerability during the pandemic.37 During the pandemic, the US implemented physical distancing to contain and slow the spread of the COVID-19 virus, which resulted in most adolescents being confined in their homes for extended periods. During this period of confinement, SGM adolescents may have been exposed to unsupportive home environments (i.e., low family support) while simultaneously being isolated from supportive peer environments (i.e., low peer support) and identity-based resources (i.e., low community support).38–40 These circumstances for SGM adolescents may have made it difficult to cope with pandemic-related stressors and made them more vulnerable to STBs.
Bisexual adolescents, particularly female bisexual adolescents, should be considered a high-priority group for STB risk because they receive less support in the home and peer environments.41–43 Bisexual adolescents represent the most significant proportion of the SGM population44 and are generally viewed with suspicion and distrust within and outside SGM communities.41,43 Future research must identify mechanisms that influence vulnerability to STBs within SGM populations because it is likely that some unique and salient risk factors within the SGM population are influencing their high risk for STBs relative to non-SGM populations.
This study has some limitations that should be noted. First, all data were collected via a self-reported survey, and, as a result, findings must be interpreted considering recall and response bias. Second, the cross-sectional design of the ABES dataset prohibits causal interpretations of our findings. For example, symptoms of poor mental health and STBs may have been present before experiencing pandemic-related stressors. Third, our analyses have limitations due to small sample sizes (e.g., ~3% of high school students identified as gay/lesbian) and no assessment of gender identity.
Similarly, the race/ethnic categories used for this study rely on the federal guidelines established in 1997 and may not reflect the racial and ethnic diversity of the US population.19,45 Fourth, there was considerable missing data for the question related to suicide attempts (~11% of the sample), which may bias estimates based on patterns response and missingness (e.g., missing not at random [MNAR]). Fifth, our measure of pandemic-related stressors reflects a count of adverse experiences but does not account for the frequency, intensity, or persistence of these adverse experiences. Future studies will be needed to apply psychometrically robust measures of pandemic-related stressors to investigate nuances of the observed relationship between pandemic-related stressors and STBs by type and frequency of stressors.
The pandemic created extraordinary personal and social challenges for everyone throughout the US.11 Adolescents may have been particularly vulnerable to suicide and STBs during the pandemic because of dramatic disruptions to their routine, including the rapid shift of schools and classrooms to virtual settings, severe social isolation and economic hardship experienced by families, and increased access to firearms and weapons.44,46,47 Importantly, our data highlighted that adolescents with marginalized identities based on sex and sexual orientation, such as SGM female adolescents, had elevated STBs compared with their peers, and future research should explore how combinations of multiple marginalized identities influence STB risk among adolescents. Overall, researchers must continue to address the gaps in understanding risk and protective factors for STBs during adolescence, particularly identifying risk and protective factors that are salient to vulnerable and underserved adolescent populations, which can be used to inform equitable solutions to reduce STBs in the adolescent population.
Supplementary Material
Study Highlights.
The COVID-19 pandemic created extraordinary sources of stress for US youth.
These stressors are related to suicidal thoughts and behavior (STB) among US youth.
SGM youth who reported pandemic-related stressors had elevated STB risk.
Females who identify as bisexual may be particularly vulnerable to STBs.
Funding
This research was primarily supported by Oklahoma Tobacco Settlement Endowment Trust (https://tset.ok.gov/), contract number R23-02. Manuscript preparation was additionally supported by the National Institute on Minority Health and Health Disparities [grant number 1K01MD015295-01A1] and National Cancer Institute Cancer Center Support Grant P30CA225520 awarded to the Stephenson Cancer Center.
Disclosure of Funding and Conflicts of Interest
AYK serves as a paid expert consultant in litigation against the tobacco industry. All other authors declare that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript.
Footnotes
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REFERENCES
- 1.Ahmad FB, Anderson RN. The Leading Causes of Death in the US for 2020. Jama 2021;325(18):1829–1830. (In eng). DOI: 10.1001/jama.2021.5469. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ruch DA, Sheftall AH, Schlagbaum P, Rausch J, Campo JV, Bridge JA. Trends in Suicide Among Youth Aged 10 to 19 Years in the United States, 1975 to 2016. JAMA Netw Open 2019;2(5):e193886. (In eng). DOI: 10.1001/jamanetworkopen.2019.3886. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Joseph VA, Martínez-Alés G, Olfson M, Shaman J, Gould MS, Keyes KM. Temporal Trends in Suicide Methods Among Adolescents in the US. JAMA Netw Open 2022;5(10):e2236049. (In eng). DOI: 10.1001/jamanetworkopen.2022.36049. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ream GL. Trends in Deaths by Suicide 2014–2019 Among Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, and Other Gender/Sexual Minority (LGBTQ+) Youth. J Adolesc Health 2022;71(5):609–615. (In eng). DOI: 10.1016/j.jadohealth.2022.06.017. [DOI] [PubMed] [Google Scholar]
- 5.Gaylor EM, Krause KH, Welder LE, et al. Suicidal Thoughts and Behaviors Among High School Students - Youth Risk Behavior Survey, United States, 2021. MMWR Suppl 2023;72(1):45–54. (In eng). DOI: 10.15585/mmwr.su7201a6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ivey-Stephenson AZ, Demissie Z, Crosby AE, et al. Suicidal Ideation and Behaviors Among High School Students - Youth Risk Behavior Survey, United States, 2019. MMWR Suppl 2020;69(1):47–55. (In eng). DOI: 10.15585/mmwr.su6901a6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Stone DM, Mack KA, Qualters J. Notes from the Field: Recent Changes in Suicide Rates, by Race and Ethnicity and Age Group - United States, 2021. MMWR Morb Mortal Wkly Rep 2023;72(6):160–162. (In eng). DOI: 10.15585/mmwr.mm7206a4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Franklin JC, Ribeiro JD, Fox KR, et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull 2017;143(2):187–232. (In eng). DOI: 10.1037/bul0000084. [DOI] [PubMed] [Google Scholar]
- 9.Favril L, Yu R, Uyar A, Sharpe M, Fazel S. Risk factors for suicide in adults: systematic review and meta-analysis of psychological autopsy studies. Evid Based Ment Health 2022;25(4):148–155. (In eng). DOI: 10.1136/ebmental-2022-300549. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Anderson KN, Swedo EA, Trinh E, et al. Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students - Adolescent Behaviors and Experiences Survey, United States, January-June 2021. MMWR Morb Mortal Wkly Rep 2022;71(41):1301–1305. (In eng). DOI: 10.15585/mmwr.mm7141a2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Krause KH, Verlenden JV, Szucs LE, et al. Disruptions to School and Home Life Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021. MMWR Suppl 2022;71(3):28–34. (In eng). DOI: 10.15585/mmwr.su7103a5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Tanz LJ, Dinwiddie AT, Mattson CL, O’Donnell J, Davis NL. Drug Overdose Deaths Among Persons Aged 10–19 Years - United States, July 2019-December 2021. MMWR Morb Mortal Wkly Rep 2022;71(50):1576–1582. (In eng). DOI: 10.15585/mmwr.mm7150a2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Anderson KN, Johns D, Holland KM, et al. Emergency Department Visits Involving Mental Health Conditions, Suicide-Related Behaviors, and Drug Overdoses Among Adolescents - United States, January 2019-February 2023. MMWR Morb Mortal Wkly Rep 2023;72(19):502–512. (In eng). DOI: 10.15585/mmwr.mm7219a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Friedman J, Godvin M, Shover CL, Gone JP, Hansen H, Schriger DL. Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021. Jama 2022;327(14):1398–1400. (In eng). DOI: 10.1001/jama.2022.2847. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Charpignon ML, Ontiveros J, Sundaresan S, et al. Evaluation of Suicides Among US Adolescents During the COVID-19 Pandemic. JAMA Pediatr 2022;176(7):724–726. (In eng). DOI: 10.1001/jamapediatrics.2022.0515. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Rico A, Brener ND, Thornton J, et al. Overview and Methodology of the Adolescent Behaviors and Experiences Survey - United States, January-June 2021. MMWR Suppl 2022;71(3):1–7. (In eng). DOI: 10.15585/mmwr.su7103a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance—United States, 2017. MMWR Surveillance Summaries 2018;67(8):1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Underwood JM, Brener N, Thornton J, et al. Overview and Methods for the Youth Risk Behavior Surveillance System - United States, 2019. MMWR Suppl 2020;69(1):1–10. (In eng). DOI: 10.15585/mmwr.su6901a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Budget OoMa. Initial Proposals For Updating OMB’s Race and Ethnicity Statistical Standards In: Office of Information and Regulatory Affairs OoMaB, Executive Office of the President, ed. Federal Register; 2023:10. [Google Scholar]
- 20.Mantey DS, Yockey RA, Springer AE. Digital screen time and suicidality during high school: How important is cyberbullying? A mediation analysis using the youth risk behavioral surveillance survey, 2011–2019. Prev Med 2023;166:107330. (In eng). DOI: 10.1016/j.ypmed.2022.107330. [DOI] [PubMed] [Google Scholar]
- 21.Hinduja S, Patchin JW. Bullying, cyberbullying, and suicide. Arch Suicide Res 2010;14(3):206–21. (In eng). DOI: 10.1080/13811118.2010.494133. [DOI] [PubMed] [Google Scholar]
- 22.Garnett BR, Masyn KE, Austin SB, Miller M, Williams DR, Viswanath K. The intersectionality of discrimination attributes and bullying among youth: an applied latent class analysis. J Youth Adolesc 2014;43(8):1225–39. (In eng). DOI: 10.1007/s10964-013-0073-8. [DOI] [PubMed] [Google Scholar]
- 23.Walker R, Francis D, Brody G, Simons R, Cutrona C, Gibbons F. A Longitudinal Study of Racial Discrimination and Risk for Death Ideation in African American Youth. Suicide Life Threat Behav 2017;47(1):86–102. (In eng). DOI: 10.1111/sltb.12251. [DOI] [PubMed] [Google Scholar]
- 24.Dasagi M, Mantey DS, Harrell MB, Wilkinson AV. Self-reported history of intensity of smoking is associated with risk factors for suicide among high school students. PLoS One 2021;16(5):e0251099. (In eng). DOI: 10.1371/journal.pone.0251099. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Gilreath TD, Connell CM, Leventhal AM. Tobacco use and suicidality: latent patterns of co-occurrence among black adolescents. Nicotine Tob Res 2012;14(8):970–6. (In eng). DOI: 10.1093/ntr/ntr322. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Corraini P, Olsen M, Pedersen L, Dekkers OM, Vandenbroucke JP. Effect modification, interaction and mediation: an overview of theoretical insights for clinical investigators. Clin Epidemiol 2017;9:331–338. (In eng). DOI: 10.2147/clep.S129728. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.King TL, Shields M, Sojo V, et al. Expressions of masculinity and associations with suicidal ideation among young males. BMC Psychiatry 2020;20(1):228. (In eng). DOI: 10.1186/s12888-020-2475-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Clark LH, Hudson JL, Rapee RM, Grasby KL. Investigating the impact of masculinity on the relationship between anxiety specific mental health literacy and mental health help-seeking in adolescent males. J Anxiety Disord 2020;76:102292. (In eng). DOI: 10.1016/j.janxdis.2020.102292. [DOI] [PubMed] [Google Scholar]
- 29.Labouliere CD, Kleinman M, Gould MS. When self-reliance is not safe: associations between reduced help-seeking and subsequent mental health symptoms in suicidal adolescents. Int J Environ Res Public Health 2015;12(4):3741–55. (In eng). DOI: 10.3390/ijerph120403741. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Miranda-Mendizabal A, Castellví P, Parés-Badell O, et al. Gender differences in suicidal behavior in adolescents and young adults: systematic review and meta-analysis of longitudinal studies. Int J Public Health 2019;64(2):265–283. (In eng). DOI: 10.1007/s00038-018-1196-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Seedall RB, Anthony JC. Monitoring by Parents and Hypothesized Male-Female Differences in Evidence from a Nationally Representative Cohort Re-sampled from Age 12 to 17 Years: An Exploratory Study Using a “Mutoscope” Approach. Prev Sci 2015;16(5):696–706. (In eng). DOI: 10.1007/s11121-014-0517-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Thompson MP, Ho CH, Kingree JB. Prospective associations between delinquency and suicidal behaviors in a nationally representative sample. J Adolesc Health 2007;40(3):232–7. (In eng). DOI: 10.1016/j.jadohealth.2006.10.016. [DOI] [PubMed] [Google Scholar]
- 33.Jokinen J, Talbäck M, Feychting M, Ahlbom A, Ljung R. Life expectancy after the first suicide attempt. Acta Psychiatr Scand 2018;137(4):287–295. (In eng). DOI: 10.1111/acps.12842. [DOI] [PubMed] [Google Scholar]
- 34.Kotila L, Lönnqvist J. Adolescent suicide attempts: sex differences predicting suicide. Acta Psychiatr Scand 1988;77(3):264–70. (In eng). DOI: 10.1111/j.1600-0447.1988.tb05119.x. [DOI] [PubMed] [Google Scholar]
- 35.Victor SE, Trieu TH, Seymour NE. Associations with LGBTQ+ mental health disparities during the COVID-19 pandemic. Psychology & Sexuality 2023:1–18. DOI: 10.1080/19419899.2023.2179938. [DOI] [Google Scholar]
- 36.Mitchell KJ, Ybarra ML, Banyard V, Goodman KL, Jones LM. Impact of the COVID-19 Pandemic on Perceptions of Health and Well-Being Among Sexual and Gender Minority Adolescents and Emerging Adults. LGBT Health 2022;9(1):34–42. (In eng). DOI: 10.1089/lgbt.2021.0238. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Poštuvan V, Podlogar T, Zadravec Šedivy N, De Leo D. Suicidal behaviour among sexual-minority youth: a review of the role of acceptance and support. The Lancet Child & Adolescent Health 2019;3(3):190–198. DOI: 10.1016/S2352-4642(18)30400-0. [DOI] [PubMed] [Google Scholar]
- 38.Fish JN, McInroy LB, Paceley MS, et al. “I’m Kinda Stuck at Home With Unsupportive Parents Right Now”: LGBTQ Youths’ Experiences With COVID-19 and the Importance of Online Support. J Adolesc Health 2020;67(3):450–452. (In eng). DOI: 10.1016/j.jadohealth.2020.06.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Salerno JP, Gattamorta KA, Williams ND. Impact of family rejection and racism on sexual and gender minority stress among LGBTQ young people of color during COVID-19. Psychological Trauma: Theory, Research, Practice, and Policy 2023;15:637–647. DOI: 10.1037/tra0001254. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.O’Brien RP, Parra LA, Cederbaum JA. “Trying My Best”: Sexual Minority Adolescents’ Self-Care During the COVID-19 Pandemic. Journal of Adolescent Health 2021;68(6):1053–1058. DOI: 10.1016/j.jadohealth.2021.03.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Dodge B, Herbenick D, Friedman MR, et al. Attitudes toward Bisexual Men and Women among a Nationally Representative Probability Sample of Adults in the United States. PLoS One 2016;11(10):e0164430. (In eng). DOI: 10.1371/journal.pone.0164430. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Hayfield N, Clarke V, Halliwell E. Bisexual women’s understandings of social marginalisation: ‘the heterosexuals don’t understand us but nor do the lesbians’. Feminism & Psychology 2014;24:352–372. DOI: 10.1177/0959353514539651. [DOI] [Google Scholar]
- 43.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003;129(5):674–697. (In eng). DOI: 10.1037/0033-2909.129.5.674. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Jones SE, Ethier KA, Hertz M, et al. Mental Health, Suicidality, and Connectedness Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021. MMWR Suppl 2022;71(3):16–21. (In eng). DOI: 10.15585/mmwr.su7103a3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Borrell LN, Goodwin RD. The Use and Interpretation of Race and Ethnicity in Research on Tobacco and Nicotine Products. Nicotine Tob Res 2023;25(8):1411–1412. (In eng). DOI: 10.1093/ntr/ntad082. [DOI] [PubMed] [Google Scholar]
- 46.Kemal S, Krass P, Brogan L, Min J, Quarshie WO, Fein JA. Identifying Suicide Risk in Adolescents With Firearm Access: Screening in the Emergency Department. Academic Pediatrics 2023;23(1):165–171. DOI: 10.1016/j.acap.2022.05.011. [DOI] [PubMed] [Google Scholar]
- 47.Miller M, Zhang W, Azrael D. Firearm Purchasing During the COVID-19 Pandemic: Results From the 2021 National Firearms Survey. Ann Intern Med 2022;175(2):219–225. (In eng). DOI: 10.7326/m21-3423. [DOI] [PMC free article] [PubMed] [Google Scholar]
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