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. Author manuscript; available in PMC: 2008 Dec 8.
Published in final edited form as: J Clin Child Adolesc Psychol. 2008 Apr;37(2):448–455. doi: 10.1080/15374410801955789

Suicidal Behaviors among Adolescents in Puerto Rico: Rates and Correlates in Clinical and Community Samples

Jennifer Jones 1, Rafael Roberto Ramirez 2, Mark Davies 3, Glorisa Canino 4, Renee D Goodwin 5
PMCID: PMC2597157  NIHMSID: NIHMS78735  PMID: 18470780

Abstract

This study examined rates and correlates of suicidal behavior among youth on the island of Puerto Rico. Data were drawn from two probability samples, one clinical (n = 736) and one community-based sample (n = 1,896), of youth ages 12 -17. Consistent with previous studies in Mainland adolescent populations, our results demonstrate that most psychiatric disorders are associated with significantly increased likelihood of suicidal behaviors. These findings provide critical new information by demonstrating specificity in the link between psychiatric disorders and suicidal behaviors. These data also suggest consistency in the links in both clinical and community samples, and by gender. Implications for clinical practice, public health programs, and methodological issues in the investigation of the correlates of suicidal behaviors in clinical and community settings are discussed.

Adolescent suicide, the third leading cause of death among youth 15-19 years old, is a major public health concern. The prevalence and incidence of suicide vary with sociodemographic variables, including ethnicity. The Centers for Disease Control and Prevention (CDC) and the National Household Survey on Drug Abuse (NHSDA) have reported the highest rates of suicide attempts in the United States among Latina adolescents (Gruenbaum et al., 2004; NHSDA, 2003). Research on suicidal behaviors (SB) in specific minority groups is relatively scant, and the factors associated with increased rates of SB among Latinos and Latino sub-groups are not known. This paper examined risk factors associated with SB among Puerto Rican adolescents on the island of Puerto Rico.

Using the results of previous studies, we chose to examine the association between a wide range of potential correlates, including psychiatric disorders and psychosocial factors, and the likelihood of SB among adolescents in Puerto Rico (Lewinsohn et al., 1996; Gould et al, 1998). Consistent with previous research examining SB (Gould et al., 1998), we combined suicidal ideation and/or suicide attempts into one variable, SB. Although this is a potential limitation of the study, we felt that combining these variables into one category that examined all SB would be a valuable contribution to the literature for the following reasons: 1) there is a paucity of information regarding SB among Latino sub-groups; 2) suicidal ideation generally precedes a suicide attempt (Lewinsohn et al., 1996); and 3) studies have shown similar risk factors associated with both suicidal ideation and attempt (Gould et al., 1998; Lewinsohn et al., 1996). As SB are frequently found among youth with mental health problems, we examined these relationships in a community-based household sample of adolescents ages 12 to 17 from the island of Puerto Rico and in a probability sample of adolescents in the same age range referred to treatment. Previous studies have consistently found links between psychiatric disorders and SB. Separate analyses were performed here because findings have been mixed on some of the associations between specific mental disorders (e.g., anxiety disorders) and SB. To address this issue in adolescents, we used identical methods for case ascertainment, assessment, and analysis for the two samples. We examined gender differences because SB in adolescents and adults shows significant variation by gender (Gould et al., 1998).

There were three main goals of the study. First, the study estimated the association between psychiatric disorders and psychosocial factors and the likelihood of SB among youth in Puerto Rico. Second, the study tested whether the relationships between psychiatric disorders and psychosocial risk factors and SB vary by setting. Third, the study tested for differences in the relationships between psychiatric disorders and psychosocial risk factors and SB by gender.

Methods

Participants

The samples were two representative random samples; an island wide sample and a clinic sample. The combined sample included youth ages 4 to 17 years, but the current study examined a sub-sample of the community and clinic samples to include adolescents between the ages of 12 to 17 years. The mean age for the community sample was 14.5 years old and 14.8 years old for the clinical sample. The gender distribution was as follows: community sample: 44.8% females and 46.8% males; clinical sample: 34.9% females and 73.5% males. The sample and the methods of the samples have been described in detail elsewhere (Canino et al., 2004).

Measures

Psychiatric diagnosis and suicidal behaviors

DSM-IV psychiatric disorders, suicidal ideation and suicide attempts during the last year were assessed using the Spanish language version of the DISC-IV. The test-retest reliability of the DISC-IV has been reported in both Spanish-speaking and English-speaking clinic samples yielding comparable results (Bravo et al., 2001). A suicidal behavior (SB) was indicated when endorsed by either parent or child informant. “Suicidal ideation” was indicated by a positive response to the question “In the last year did you [he/she if parent was informant] ever think seriously about killing yourself?” “Suicide attempt” was indicated by a positive response to the question “Have you [he/she] ever, in your [his/her] whole life, tried to kill yourself [him/herself] or made a suicide attempt?” Due to low rates of individual SB that would have limited the power of the analyses, the variable “SB,” which combined suicidal ideation or suicidal attempts was used throughout the analyses.

Comorbidity

It was defined as one or more co-occurring DSM-IV Axis I disorders other than mood disorder(s).

PIC-GAS

Overall global impairment in functioning at home, at school, and with peers was measured by the Parent Lay Interviewer Children’s Global Assessment Scale (PIC-GAS). The Spanish translation of the PIC-GAS has been shown to be moderately reliable (test-retest ICC = 0.69) (Bird et al, 1996).

Other Psychiatric Variables

Perfectionism

This scale consisted of five items derived from the DISC-IV generalized anxiety disorder module. The scale was dichotomous and considered positive if either the child or parent endorsed any of these five items.

Aggressive behavior

This scale consisted of one item derived from the conduct disorder module of the DISC-IV that assessed whether the child ever engaged in physical fighting in which someone was hurt or could have been hurt. The scale was dichotomous and considered positive if either the child or parent endorsed the item.

Runaway behavior

This scale consisted of one item derived from the conduct disorder module of the DISC-IV that asked whether the child ever ran away from home overnight. The scale was dichotomous and considered positive if either the child or parent endorsed the item.

Sexual behavior

This scale consisted of 11 items derived from the Youth Risk Behavior Survey (YBRBS, CDC, 2004) including sexual intercourse, birth control, pregnancy, and sexually transmitted diseases.

Drug use

Problem drug use was defined as the endorsement of at least one criterion for a diagnosis of abuse or dependence in the substance use modules from the DISC IV, and Used drugs 6 or more times in past year was comprised of those who endorsed the use of marijuana or other substances 6 or more times during the past year.

Problem drinking

This variable was comprised of subjects who endorsed at least one criterion of alcohol abuse or dependence and those that met DSM-IV, DISC criteria for alcohol abuse and/or dependence.

Family mental health history

We used a shortened and revised version of the Family Psychiatric History Screen for Epidemiologic Studies (FHS) developed by Lish, Weissman, Adams, Hoven, and Bird (1995). The FHS measures history of psychiatric illness and psychiatric service use in primary caretakers.

Sociodemographic factors

Sociodemographic factors included gender, age, and socioeconomic status as defined by subject’s perception of poverty.

Perceived poverty

Perception of poverty was assessed using a 5-point scale designed to assess a person’s appraisal of his or her level of poverty including “live very well,” “live comfortably,” “live from check to check,” “almost poor,” and “poor.” Perception of poverty was used instead of other more typical indicators of SES because previous analyses using the current data have not shown any relationship between psychiatric disorders and income or parental education in Puerto Rico (Canino et. al., 2004). And, although there is a consistent link between low SES and psychiatric disorders in the literature (Dohrenwend 1990), results from previous studies in this (Canino et al., 2004) and other communities (Costello et al., 2001) suggest that income questions that are effective in capturing SES in most populations with a wide range of socioeconomic levels, do not adequately capture SES in homogenously impoverished communities. The items used to assess perception of poverty were adapted from a measure developed by Gore and colleagues (1992). Results from a pilot study showed an intra-class correlation of .805 (CI = .74 to .86) for this scale.

Procedures

The procedures of the study have been described in detail elsewhere (Canino et al, 2004). The survey was carried out between 1999 and 2000, following approval by the University of Puerto Rico’s Institutional Review Board. Informed consent was obtained from the child’s primary caretaker and youth 11 – 17 years old. The child’s biological mother was the adult informant in 89.4% of the cases. Interviews took place in the child’s home and were conducted by different interviewers for the parent and child (Each interviewer was blind to the results of the other’s interview).

Statistical analyses

The samples were weighted to represent the population of children ages 4 – 17 in Puerto Rico (community sample) and the Puerto Rican population of medically indigent children of the same age range who received mental health services from January 1, 1998 to May 31, 1998 (clinical sample). Sampling weights reflect differences in selection probability due to the complex sample design. For the treatment sample, sampling weights include an additional adjustment for non-response. All statistical analyses were conducted using SUDAAN software (release 8.0) (Research Triangle Institute, 2001). All parameters were estimated with Taylor series linearization methods and robust standard errors (Binder, 1983).

Logistic regression was used to estimate crude and adjusted odds ratios when examining the correlates and patterns of comorbidity with SB, adjusted for age, gender, interaction of age and gender, and perception of poverty. Suicidal behavior was regressed on each of the other psychiatric symptoms controlling for age, gender, interaction of age and gender, perception of poverty and any mood, anxiety, disruptive, or substance use disorders. Because the two samples relate to different populations, and because the sampling designs were different, we carried out analyses in each sample separately rather than combining the data into a single analysis. To compare estimates from the two samples, we computed a test statistic composed of the difference in the two regression estimates, divided by an estimate of the standard error of that difference (see Footnote 1). Under the null hypothesis of no difference and with the sample sizes available for these analyses, this statistic will be distributed as a standard normal variable (Freeman, 1962).

Results

Sociodemographic Characteristics

Table 1 lists the distribution of SB by age, gender, and perception of poverty for the clinical and community samples. Approximately one out of ten (10.3%) of Puerto Rican adolescents in the entire community sample reported SB. Among those in the entire community sample, 9.0% of males and 11.0% of females reported SB which suggests equal reporting between genders.

In the entire clinical sample, the prevalence of SB was higher with 37.9% of adolescents reporting SB. Among those in the entire clinical sample, 31.2% of males and 50.7 % of females reported SB, with 30.7% between the ages of 12-14 years old, and 42.2% between the ages of 15-17 years old.

Prevalence of Psychiatric Diagnoses

Table 2 lists the prevalence rates and adjusted odd ratios for psychiatric diagnoses for the community and clinical samples. In the community sample, meeting criteria for any diagnosis was significantly associated with an increase in the likelihood of SB (OR = 4.9, CI = 2.6–8.7); as was meeting criteria for a comorbid diagnosis (OR = 4.3, CI = 2.4–7.6). Similarly, in the clinical sample, any diagnosis (OR = 3.3, CI = 2.1–5.2); or any comorbid diagnosis (OR = 3.2, CI = 2.0–4.9) was also associated with a significant increase in the likelihood of SB.

Community sample

For most psychiatric diagnoses, adolescents with SB had significantly higher rates of the diagnosis than those without SB. Substance problems showed the strongest associations with suicidal behaviors: substance abuse disorders (OR = 6.9, CI = 1.6–29.2), problem drug use during the last year (OR = 17.2, CI = 3.5–85.0), using drugs 6 or more times in the past year (OR = 14.1, CI = 3.2–61.7), and problem drinking (OR = 6.8, CI = 2.4–19.1) were associated with increased likelihood of SB, compared with youth without these conditions.

Clinical sample

Similar to the community sample, in the clinical sample most psychiatric disorders were associated with increased risk of SB, except for Dysthymia, Generalized Anxiety Disorder, and ADHD (see Table 2). Conduct disorder (OR = 6.1, CI=3.4-11.2) was the strongest predictor of suicidal behavior.

Adjusted association between psychiatric disorders and SB

In the community sample, after simultaneously adjusting for all types of psychiatric disorders, only anxiety was independently associated with increased risk for SB (see Table 3). In contrast, in the clinical sample, mood and disruptive disorders were independently associated with increased risk for SB after adjustment.

Diagnostic differences by gender

For girls in the community sample, only anxiety disorders were independently associated with increased risk of SB (See Table 4). Yet, for girls in the clinical sample, only mood disorders were independently associated with increased risk of SB. The pattern for boys was similar in the community and clinical samples, with disruptive disorders being the only disorder independently contributing to the risk for SB.

Other Behavioral Problems

After adjusting for the effects of age, gender, interaction of age and gender, perception of poverty, and other psychiatric disorders, runaway behavior, sexual intercourse and aggressive behavior were independently associated with SB in the community and clinical samples, as was family mental health history in the clinical sample only (see Table 5).

Difference between the community and clinical samples

The strength of the relationships was not significantly different between the community and clinical samples on any of the variables in Tables 1-5, with the exception of dysthymia (Table 2; Z = 2.19, p < .02); but, after adjusting for multiple comparisons, there were no significant differences in these relationships.

Discussion

In this study, we investigated the rates and correlates of SB among adolescents in Puerto Rico. Our findings are consistent with and extend available data on the relationship between psychiatric disorders and psychosocial risk factors for SB among Latino youth. First, we found that the rates of SB among youth in Puerto Rico are generally consistent with rates in other samples of youth in the community (Lewinsohn et al 1996; Gould et al 1998). We also found these rates are lower than previous reports of rates of SB among Latino youth on the Mainland. Second, our results reveal new information on linkages between specific psychiatric disorders and SB by gender among Latino youth. Third, our results suggest that the association between psychiatric disorders and SB among youth are relatively consistent across clinical and community settings.

Our results indicate that rates of SB among youth in Puerto Rico are relatively consistent with previous findings (Gould et al, 1998) among other racial and ethnic groups in the general U.S. population. We found prevalence rates of 10.3% for SB (7.3% of ideation and 5.9% of attempts) in this community sample of Puerto Rican adolescents between the ages of 12 and 17 years old. Similarly, previous studies have estimated that the lifetime prevalence of attempts in this age group was between 6 and 10% (Lewinsohn et al., 1996). It is interesting to note, however, that rates of SB among both males and females in this sample of Puerto Rican adolescents were much lower than rates among Latinas in the Mainland. The most recently available data from the CDC reported that nationwide 8.4% of students had attempted suicide in the preceding 12 months of the survey. However among ethnic groups within the same age group, 9.3% of white females and 9.8% of black females had made a suicide attempt compared to 14.9% of Latinas—the highest reported rates of suicide attempts in the United States (CDC 2006). The 2000 National Household Survey on Drug Abuse (NHSDA, 2003) also found higher rates of SB (ideation and attempts) among U.S. born Latina adolescents between 12 and 17 years old compared to other youth. In that study, U.S. born Latina adolescents were at higher risk for SB than foreign-born Latinas. (These rates were similar across Latino subgroups.) The reason that our rates of SB are more similar to rates of SB for non-Latinos than for Latinas on the Mainland is not known. The difference may be related to higher levels of family involvement and the extended family’s central role in Puerto Rican life (Bird et al., 1982). Also, Latinos on the Mainland must contend with the additional stressors of discrimination, acculturation, and intergenerational conflict stemming from parental restriction on female autonomy that may increase the risk for SB, particularly among Latinas (Zayas et al., 2005).

Our findings suggest that psychosocial behaviors have an independent and significant relationship with SB, beyond that of psychiatric disorders, among youth in both clinical and community samples. After controlling for the effects of age, gender, perception of poverty, and psychiatric diagnosis, we found that runaway behavior, having had sexual intercourse, and aggressive behavior were significantly associated with SB for both the community and clinical samples of Puerto Rican youth. Of note, the odds ratio for the community sample was twice as high for runaway behaviors than rates found in a similar study that examined risk factors among a sample of geographically and ethnically diverse adolescents, aged 9 to 17 years, in the Mainland and Puerto Rico (Gould et. al., 1998).

Finally, we found consistency in the relationship between psychiatric disorders and suicidal behavior in both the clinical and community samples. Though the relative strength of these linkages appeared to differ slightly, statistical tests indicated no significant difference. The combined use of clinical and community samples and measures using identical methods in the current study sheds new light on this issue.

Implications for Future Research, Policy and Practice

Consistent with previous literature that has documented that psychiatric diagnoses are a risk factor for SB (Gould et al, 2003), we found strong links between nearly every psychiatric disorder and suicidal behavior. Specifically, we found that anxiety disorders were associated with significantly increased SB among girls. These findings are relatively consistent with those of Gould et al. who found panic attack associated with SB among youth in the community. If replicated, this finding may be an important avenue for future research into the etiology of SB in youth in terms of the potential link with anxiety, and have important implications for the identification of girls who may be at risk for SB. Our results also showed that mood disorders were strongly associated with SB among girls in clinical settings. This finding is consistent with previous findings. Although the associations between substance use disorders and SB were initially significant in the community sample, it is noteworthy that after controlling for the independent effects of psychiatric diagnoses on the risk of SB, only disruptive disorder remained significant for boys. Previous studies have shown substance use to be associated with SB among adolescents (Gould et al., 1998). Yet, our findings suggest it may be that disruptive behavior disorders mediate the relationship between substance use and suicide. Symptoms of disruptive disorder such as aggression and antisocial behavior are most likely found in completed suicide for boys and may underlie a proclivity for engaging in SB (Shaffer et al., 1996). As these data reveal a distinction in presentation for boys and girls who are at risk for SB, the potential importance of this knowledge in developing interventions that take into account gender differences in behavior cannot be underestimated.

Strengths of the study included use of a large sample, and data from both adolescent and caregiver was available for all subjects. The study assessed both a community and clinical population using identical methods, which allowed for unique comparisons. There are also a number of limitations to keep in mind when interpreting our results. Because the total number of suicidal ideators and suicide attempters was relatively small, we combined these groups to maximize power. Future studies should aim to separate these groups to assess if and what risk factors differentiate these groups. Although the response rates were high in this study, non-responder data could be a potential source of bias. Also, the measure used in this study to assess SES—perception of poverty—was based on an individual’s appraisal of his or her economic conditions which may have been tempered by his or her psychiatric status. In addition, the cross-sectional study design necessarily limits making any conclusions about causality between suicidal behavior and the psychosocial factors examined. Therefore, future studies that are longitudinal and have larger sample size may be able to provide more detailed information on male and female ideators and attempters.

Acknowledgments

Financial Support: Data for this study was obtained from the National Institute of Mental Health R01 - MH54827-01,Canino (PI), and P20 MD000537-01, Canino (PI) from the National Center for Minority Health Disparities. Preparation for this article was supported by Grant 1 U10 MHO66762-01 Long-term Minority Research Supplement from the National Institute of Mental Health awarded to Jennifer Jones. The authors thank Prudence Fisher for sharing her expertise in the phenomenology of suicidal behavior, and Ansley Roche and Chia-Ying Wei for their assistance in the preparation of the manuscript.

Footnotes

1

Let BM be the regression coefficient for the community sample, and SM be its standard error. Let BL be the comparable coefficient for the clinical sample, and SL be its standard error. The test statistic, which under the null hypothesis is asymptotically distributed as a standard normal deviate, is z = (BM – BL) / (SM2 + SL2)1/2.

Contributor Information

Jennifer Jones, Department of Child and Adolescent Psychiatry, New York State Psychiatric Institute/Columbia University

Rafael Roberto Ramirez, Behavioral Sciences Research Institute, University of Puerto Rico

Mark Davies, Department of Child and Adolescent Psychiatry, New York State Psychiatric Institute/Columbia University

Glorisa Canino, Behavioral Sciences Research Institute, University of Puerto Rico

Renee D Goodwin, Department of Epidemiology, Mailman School of Public Health Columbia University.

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