Abstract
Background
Although extensive studies on adolescent suicidal behavior have been conducted in developed countries such as the United States, little data exist on risk factors for suicide among adolescents in culturally and socially disadvantages settings, such as Jamaica.
Aims
To conduct a preliminary investigation of risk factors associated with suicide ideation and attempt among youths in Western Jamaica.
Methods
We conducted a cross-sectional study of 342 adolescents aged 10–19 years from 19 schools.
Results
Multivariate analysis showed that a history of self-violence, violent thoughts toward others, mental health diagnoses other than depression, and a history of sexual abuse were positively associated with suicide attempt. Sexual abuse, mental health diagnoses other than depression, self-violence, and ease of access to lethal substances/weapons were positively associated with suicide ideation.
Conclusions
We found a relatively high prevalence of suicide ideation and suicide attempts among adolescents living in Western Jamaica. An accurate understanding of the prevailing risk factors for suicide attempts will promote a more sympathetic approach to victims and facilitate prevention efforts.
Keywords: suicide, adolescent, Jamaica
Introduction
Suicide, or self-directed violence, is increasingly becoming a notable global public health problem, and it is now the thirteenth leading cause of death worldwide (World Health Organization [WHO], 2002). In 2000, half of the estimated 1.6 million deaths due to violence were attributed to suicide. Despite this high number of reported incidences, the reported proportions may not accurately represent the full magnitude of the problem due to underreporting or misclassification on death certificates (WHO, 2002). Only a minority of suicide ideators actually kill themselves, and only about 10% of suicide attempters actually succeed (WHO, 2002). Young children and adolescents are not untouched by this epidemic. Globally, suicide ranks among the top three leading causes of adolescent mortality (WHO, 2001), with rates steadily increasing in this age cohort (Wasserman, Cheng, & Jiang, 2005). In the United States, suicide is reported to be the third leading cause of death among youths (Centers for Disease Control and Prevention [CDC], 2009), and in 2007, 15% of the surveyed adolescents reported seriously considering suicide (CDC, 2008). A study conducted in China reports suicide as the leading cause of death among adolescents and young adults (Phillips, Li, & Zhang, 2002). A prevalence of 23–31% for suicide ideation is reported among adolescents in Hong Kong (Chan et al., 2008). Suicidal ideation in adolescents has also been shown to be a predictor of psychopathology and suicidal behavior in adults (Reinherz, Tanner, Berger, Beardslee, & Fitzmaurice, 2006).
Suicide causation is highly complex and can vary widely based on individual and environmental influences. Mental health disorders, such as mood, anxiety, and substance-related disorders, are significantly culpable in a large proportion of suicidal behaviors (Li, Phillips, Zhang, Xu, & Yang, 2008; Moscicki, 1997; Waldrop et al., 2007); however, nonpsychological elements also play equally important roles and can often act as triggers. These include, but are not limited to, conduct disorders, sexual or physical abuse, exposure to household and peer violence, scholastic failure, poor socioeconomic status, incarceration, sexuality, adolescent struggles, sleep disorders, family adversity, poor familial and social connectedness, and other life stressors (Beautrais, 2000; CDC, 2009; Chan et al., 2008; Fergusson, Woodward, & Horwood, 2000; Kelly, Cornelius, & Lynch, 2002; Li et al., 2008; Maris, 2002; National Alliance on Mental Illness [NAMI], 2008; WHO, 2001). In addition, certain demographic variables such as female gender and older age have been associated with suicidal attempts and ideations (Anteghini, Fonseca, Ireland, & Blum, 2001; Blum et al., 2003; Chan et al., 2008; Waldrop et al., 2007).
Mental disorders comprise 24% of the health burden in Latin America and the Caribbean, with one out of every five children or adolescents suffering from disorders that require some intervention (Pan American Health Organization [PAHO], 2005). In a 9-country multisite health survey of 15,695 Caribbean youths aged 10–18, 15% of the adolescents reported significant emotional distress, while 12% reported having attempted suicide (Blum et al., 2003). A 2006 report indicates that approximately 3% are reported as committing suicide in Jamaica, with depression being the principal cause (Jamaica Information Service, 2006). Adolescents comprise a significant proportion of attempters: In 2001, 41% of all hospital visits made for attempted suicide involved young people aged 10–19 years (Jamaican Ministry of Health, 2001). This is higher than attempter rates in many developed countries such as the United States, where in 2001, 19% of surveyed youths reported a previous suicide attempt (CDC, 2002) and 7% in 2007 (CDC, 2008).
To the best of our knowledge, there are very limited published data on specific research addressing suicide attempts and its risk factors in the critical adolescent age group in Jamaica, and in the Caribbean as a whole. There are no data available on the prevalence of Jamaican adolescents who have seriously contemplated suicide, hence the need for research in this area. This study investigated the risk factors associated with attempted suicide and suicide ideation among adolescents in Western Jamaica. It entails our findings on the relationships between mental health, familial and social connectedness, anger management, and suicidal tendencies. In line with findings in other countries, we hypothesized that poor mental and emotional health (e.g., depression), abuse of alcohol and other substances, as well as poor familial/social connectedness would be significantly associated with both suicide ideation and attempt.
Methods
Study Design, Site, and Participants
A cross-sectional study was conducted in the parishes of St. James and Westmoreland in Western Jamaica from May–August 2006. In 2005, the total population of adolescents aged 10–19 living in the two parishes was 64,447 (Western Regional Health Authority, 2006). Out of 117 primary, junior-high, secondary, technical, and all-age schools in the parishes, 28 separate schools were selected as study sites based on location and enrollment size. Eligible participants consisted of adolescents aged 10–19 enrolled in grades 6–11 at any of the 28 selected schools. Sample size requirement for the test of a single population proportion was calculated both electronically (Lenth, 2006) and manually. A worst case 50% prevalence for suicidal behavior was used as there are no available data on the prevalence of Jamaican adolescents who have seriously considered or attempted suicide. Based on a 95% confidence interval and 5% margin of error, a total sample of 382 adolescents was required. However, only a total of 342 adolescents were recruited in the 3-month period. Students from 19 out of the 28 eligible schools participated in this study, and the proportion of participants was split equally between the two parishes (Table 1). Primary reasons for the smaller sample size included administrative barriers due to the busy period at the end of the school year, as well as nonreturn of parental consent. The purpose and objectives of the study were explained to the students at each of the schools. Students were then asked to take consent forms home to obtain parental consent. The children were also asked for their own assent to participate. No child was enrolled as a participant without both parental consent and own assent. Participation in the study was voluntary, and no incentives were provided. All study questionnaires were anonymous as no identifying information was recorded, and the students were assured that strict confidentiality would be maintained.
Table 1.
Participants’ schools by parish
Parish | Name of school | Type of school |
---|---|---|
Westmoreland (11 schools; 172 participants) | Caledonia | All ages |
Frome | Technical high school | |
Godfrey Stewart | High school | |
Little London | High school | |
Manning’s | High school | |
Mount Grace | Primary & junior high school | |
New Hope | Primary & junior high school | |
New Roads | All ages | |
Petersfield | High school | |
Sheffield | All ages | |
Williamsfield | All ages | |
St. James (8 schools; 170 participants) | Anchovy | Primary school |
Cambridge | High school | |
Cornwall College | High school | |
Garlands | Primary & junior high school | |
Herbert Morrison | Technical high school | |
John’s Hall | All ages | |
Springfield | All ages | |
St. James | High school |
Ethical Approval
The Institutional Review Board of the University of Alabama at Birmingham, USA, the Advisory Panel of Ethics and the Medico-Legal Affairs in the Ministry of Health, Jamaica, and the Western Regional Health Authority, Jamaica, approved the study protocol prior to its implementation.
Data Instrument and Measures
A structured self-administered 54-item questionnaire totaling 159 options was developed based on the instrument used in the 9-country Caribbean survey (Blum et al., 2003). This questionnaire covered the following topics: demographics, school performance, relationship with parents/caregivers and other family members, extrafamilial relationships, general health, substance use including alcohol, tobacco, and any illegal drugs, violence, sexual practices, history of physical and sexual abuse, mental health, suicidal thoughts, past attempts at suicide, and access to care. The selected variables were chosen based on our literature review of risk factors for suicide in other settings. The questionnaire was pilot-tested by administering it to adolescents of different ages and modified based on their understanding, questions and responses. The measures that were used are described below.
Suicide Ideation and Attempt
Lifetime suicide ideation was defined as a positive response to the following question: “Have you ever thought about killing yourself?” Lifetime suicide attempt was defined by a positive response to the question “Have you ever tried to kill yourself?”
Depression, Mental and Emotional Health
The presence of depression and other mental health problems was assessed using the following questions: “Has a doctor or healthcare provider ever told you that you were depressed?” (depression); “Has a doctor ever told you that you have an emotional or mental health problem other than depression?” – “In general, do you see yourself as a person who is mostly happy, sad, angry or frustrated?” – “During the past 2 weeks, have you felt so down or discouraged that you wondered if anything was worthwhile?” (other mental health).
Violence and Violent Tendencies
These were assessed using the items: “Do you ever think about hurting or killing someone?” – “Have you ever tried to hurt yourself on purpose?”
Difficulty Managing Anger
This was assessed using the item: “During the past month, have you had difficulty managing your anger?” Selecting three or more times was classified as a positive response.
History of Sexual and Physical Abuse
The following questions were used to assess the history and exposure to sexual and physical abuse: “Have you ever been physically abused or mistreated by anyone in your household or anyone else?” – “Has anyone in your household been physically abused?” – “Have you ever been sexually abused?” – “Has anyone in your household been sexually abused?”
Substance Abuse
Alcohol use was classified on the frequency of consumption of beer, wine, or hard liquor within the past year, while illegal substance abuse was defined as an acknowledgment of the consumption of ganga (marijuana) more than just a few times within the past year.
Familial and Social Connectedness
This measure was assessed using the questions “Can you talk to the following people about your problems? Mom, dad, friends, teachers, pastor, counselor, others.” – “How much do you feel the following people care about you? Mom, dad, friends, family, pastor, counselor, teachers.” Stating definitely/somewhat and some/a lot to any of the options were classified as positive responses. “Who do you spend your free time with? Family, Friends or alone?” was also included in this category.
Religious Affiliation
This was measured as either identifying with a church in response to “Do you attend a church?” and “In the last 3 months, how often did you go to church?” or a response to “Do you think of yourself as a religious person?”
Some of the other questions of interest included in the instrument were:
-
-
“If you ever decided to kill yourself, do you think it would solve any of your problems?”
-
-
“If you ever planned to kill yourself, could you get the things you needed to do it with?”
-
-
“Who do you live with most of the time?” and “What kind of student are you? Below average, average or above average?”
Data Analysis and Variable Selection
Data analysis was performed using SAS software, version 9.1 (SAS Institute, NC). Several variables were assessed in this study. Therefore, in order to preserve the power of the final model, preliminary crude and multivariable analyses were performed to rule out variables that were nonsignificant at the α level of 0.05. Variables of interest, those shown to be associated with suicidal behaviors in other studies as well as those significant at the set α level, were then selected for final analysis.
Descriptive analyses were performed by obtaining absolute and relative frequencies for the distributions of selected variables. The study population was divided into four groups: suicide ideators, nonsuicide ideators, suicide attempters, and nonsuicide attempters. χ2 test was used to assess differences in the distributions of the selected variables by the two groups of ideators and attempters.
To determine risk factors for suicidal behavior in the study population, multivariable logistic regression was then performed and odds ratios were generated as measures of association. Each variable of interest was individually fitted with the outcome (suicide ideation or attempt) to obtain crude associations. Gender and age were included as potential confounders. Variables that were significant in the full model and those of interest were included in the final model. Missing values for either attempt or ideation were excluded from the analyses, and a total of 332 records were analyzed.
Results
Descriptive Statistics
Suicide Attempt
82 (24.6%) of the participants reported having attempted suicide (Table 2), with females comprising 64% of this population. Approximately 24% of attempters indicated that they had been either physically abused or knew someone in their family who had been abused, while 33% reported past sexual abuse to them or a family member. About 5% reported monthly or more frequent alcohol use, while 6% indicated monthly or more frequent other substance (ganga) use. 12% reported having a depression diagnosis, and 79% reported the diagnosis of an emotional or mental health issue apart from depression and/or persistent moodiness. 12% indicated that they had no religious affiliations, while 19.5% reported having struggled to control their anger three or more times in the previous month. 52% indicated that they could easily obtain means to kill themselves with, while 56% reported that they had previously tried to hurt themselves. 70% reported a history of violence toward others, 18% considered their school performance below average, and 18% indicated that they spent most of their free time alone. Attempters significantly differed from nonattempters in the following variables: depression diagnosis (p = .03), other emotional/mental health problems (p < .01), history of sexual abuse (p < .01), suicide as a problem solver (p = .01), religious affiliation (p = .03), history of self-violence (p < .01), easy access to lethal substances/objects (p < .01), violent thoughts toward others (p < .01), difficulty managing anger (p < .01), school performance (p < .01) and solitary tendencies (p < .01).
Table 2.
Descriptive analysis of selected variables by attempted suicide
Variable | Attempted suicide: No [N = 250 (%)] | Attempted suicide: Yes [N = 82 (%)] | p |
---|---|---|---|
Gender | |||
Male | 112 (44.8) | 29 (35.4) | .13 |
Female | 138 (55.2) | 53 (64.6) | |
Age | |||
10–12 | 73 (29.2) | 27 (32.9) | .06 |
13–15 | 144 (57.6) | 36 (43.9) | |
16–19 | 33 (13.2) | 18 (22.0) | |
Depression | |||
No | 223 (93.2) | 72 (87.8) | .03* |
Yes | 13 (5.2) | 10 (12.2) | |
Other mental health problems | |||
No | 120 (48.0) | 17 (20.7) | <.01* |
Yes | 130 (52.0) | 65 (79.3) | |
Alcohol use within the past year | |||
Never | 125 (50.0) | 40 (48.8) | .69 |
One or few times only | 108 (43.2) | 34 (41.5) | |
Few times a month | 7 (2.80) | 2 (2.5) | |
Few times a week or daily | 2 (0.80) | 2 (2.5) | |
Other substance (ganga) within the past year | |||
Never | 214 (85.6) | 62 (75.6) | .14 |
One or few times only | 22 (8.8) | 10 (12.2) | |
Few times a month | 3 (1.2) | 4 (4.9) | |
Few times a week or daily | 3 (1.2) | 1 (1.2) | |
Physical abuse/Familial history | |||
No | 175 (70.0) | 55 (67.1) | .87 |
Yes | 73 (29.2) | 24 (23.5) | |
Sexual abuse/Familial history | |||
No | 202 (80.8) | 53 (64.6) | <.01* |
Yes | 41 (16.4) | 27 (32.9) | |
Talk to others? | |||
Yes | 154 (61.6) | 46 (56.1) | .12 |
No | 95 (38.0) | 33 (40.2) | |
Killing self will solve problems? | |||
No | 206 (82.4) | 47 (57.3) | .01* |
Yes | 37 (14.8) | 34 (41.5) | |
Religious affiliation? | |||
Yes | 232 (92.8) | 70 (85.4) | .03* |
No | 17 (6.8) | 12 (14.6) | |
Tried to hurt self in past? | |||
No | 196 (78.4) | 31(37.8) | <.01* |
Yes | 49 (19.6) | 46 (56.1) | |
Can easily obtain means to kill self? | |||
No | 179 (71.6) | 38 (46.3) | <.01* |
Yes | 60 (24.0) | 43 (52.4) | |
Tried to hurt others in past? | |||
No | 149 (59.6) | 25 (30.5) | <.01* |
Yes | 96 (38.4) | 57 (69.5) | |
Difficulty managing anger? | |||
No | 215 (86.0) | 61 (74.4) | <.01* |
Yes | 21 (8.4) | 16 (19.5) | |
School performance | |||
Average/above average | 230 (92.0) | 65 (79.3) | <.01* |
Below average | 11 (4.4) | 15 (18.3) | |
Spend free time | |||
With family/friends | 233 (93.2) | 66 (80.5) | <.01* |
Alone | 17 (6.8) | 15 (18.3) |
Note.
Statistically significant. Sum of N for some variables may not equal total N due to missing values – missing values were excluded from analyses.
Suicide Ideation
Of the 332 evaluated participants, 38% reported having suicide ideations (Table 3). 56% of these indicated that they had actually attempted suicide. 60% of ideators were female. 35% reported that either they or a family member had been physically abused, while 29.4% reported past sexual abuse to them or a family member. About 5.5% reported monthly or more frequent alcohol use, while 5% indicated monthly or more frequent other substance (ganga) use. 7% reported having a depression diagnosis, while 75% reported diagnosis of an emotional or mental health issue apart from depression and/or persistent moodiness. 8% indicated that they had no religious affiliations, while 17.5% reported that they struggled with controlling their anger three or more times in the previous month. 49% indicated that they could easily obtain means to kill themselves with, while about 52% reported that they had previously tried to hurt themselves. 60% reported a history of violence toward others, 13.5% considered their school performance below average, and 13.5% indicated that they spent most of their free time alone. Ideators significantly differed from nonideators in the following variables: other emotional/mental health diagnoses apart from depression (p < .01), history of physical abuse (p < .01), history of sexual abuse (p < .01), suicide as a problem solver (p = .01), religious affiliation (p = .03), history of self-violence (p < .01), easy access to lethal substances/objects (p < .01), violent thoughts toward others (p < .01), school performance (p < .01) and solitary tendencies (p = .04).
Table 3.
Descriptive analysis of selected variables by suicide ideation
Variable | Suicide ideation: No [N = 206 (%)] | Suicide ideation: Yes [N = 126 (%)] | p |
---|---|---|---|
Gender | |||
Male | 92 (44.7) | 50 (39.7) | .36 |
Female | 114 (55.3) | 76 (60.3) | |
Age | |||
10–12 | 56 (27.2) | 43 (34.1) | <.01* |
13–15 | 126 (61.2) | 56 (44.4) | |
16–19 | 24 (11.6) | 26 (20.6) | |
Depression | |||
No | 190 (92.2) | 117 (92.7) | .06 |
Yes | 12 (5.9) | 9 (7.1) | |
Other mental health problems | |||
No | 106 (51.5) | 32 (25.4) | <.01* |
Yes | 100 (48.5) | 94 (74.6) | |
Alcohol use within the past year | |||
Never | 108 (52.4) | 56 (44.4) | .37 |
One or few times only | 85 (41.3) | 57 (45.2) | |
Few times a month | 4 (2.0) | 5 (3.9) | |
Few times a week or daily | 2 (1.0) | 2 (1.6) | |
Other substance (ganga) within the past year | |||
Never | 173 (84.0) | 102 (80.9) | .50 |
One or few times only | 19 (9.2) | 13 (10.3) | |
Few times a month | 3 (1.5) | 4 (3.2) | |
Few times a week or daily | 2 (1.0) | 2 (1.6) | |
Physical abuse | |||
No | 153 (74.3) | 78 (61.9) | <.01* |
Yes | 51 (24.8) | 44 (34.9) | |
Sexual abuse | |||
No | 172 (83.5) | 86 (68.3) | .01* |
Yes | 28 (13.6) | 37 (29.4) | |
Religious affiliation? | |||
Yes | 184 (89.3) | 116 (92.1) | .48 |
No | 21 (10.2) | 10 (7.9) | |
Killing self will solve problems? | |||
No | 168 (81.6) | 86 (68.3) | .07 |
Yes | 30 (14.6) | 39 (30.9) | |
Tried to hurt self in past? | |||
No | 171 (83.0) | 57 (45.2) | <.01* |
Yes | 28 (13.6) | 65 (51.6) | |
Can easily obtain means to kill self? | |||
No | 156 (75.7) | 63 (50.0) | <.01* |
Yes | 38 (18.5) | 62 (49.2) | |
Tried to hurt others in past? | |||
No | 125 (60.7) | 50 (39.7) | <.01* |
Yes | 75 (36.4) | 76 (60.3) | |
Difficulty managing anger? | |||
No | 181 (87.8) | 95 (75.4) | .11 |
Yes | 14 (6.8) | 22 (17.5) | |
School performance | |||
Average/Above average | 189 (91.8) | 105 (83.3) | <.01* |
Below average | 10 (4.8) | 17 (13.5) | |
Spend free time | |||
With family/friends | 192 (93.2) | 108 (85.7) | .04* |
Alone | 14 (6.8) | 17 (13.5) |
Note.
Statistically significant. Sum of N for some variables may not equal total N due to missing values – missing values were excluded from analyses.
Multivariable Analyses
Due to nonconvergence of some of the data resulting from too few cell numbers, alcohol abuse and ganga use were combined under “substance abuse.” Results from the multivariable analyses are detailed in Tables 4 and 5. Models were adjusted for age and gender.
Table 4.
Crude and adjusted odds ratios from multivariate analyses by suicide attempt
Variable | Crude OR (95% CI) | Adjusted OR (95% CI) | p |
---|---|---|---|
Gender: Female vs. male | 1.48 (0.88–2.48) | 1.52 (0.74–3.12) | .25 |
Sexual abuse/familial history | 2.51 (1.41–4.44) | 2.43 (1.05–5.61) | .03** |
Physical abuse/familial history | 1.04 (0.63–1.82) | 0.52 (0.23–1.14) | .10 |
Depression | 2.49 (1.05–5.91) | 0.50 (0.12–2.12) | .35 |
Other mental health problems | 3.52 (1.95–6.36) | 3.34 (1.53–7.31) | .01** |
Ever think of hurting others | 3.54 (2.07–6.04) | 2.21 (1.04–4.72) | .03** |
Think killing self will solve problems | 4.02 (2.29–7.07) | 1.93 (0.87–4.26) | .10 |
Tried to hurt self in the past | 5.93 (3.41–10.31) | 4.02 (1.87–8.59) | <.01** |
Can easily obtain means to kill self | 3.37 (1.99–5.70) | 1.66 (0.77–3.24) | .19 |
Difficulty managing anger | 2.68 (1.32–5.46) | 1.15 (0.40–3.24) | .79 |
Substance use | 2.03 (0.80–5.09) | 0.77 (0.18–3.24) | .72 |
Religious affiliation | 2.33 (1.06–5.13) | 2.39 (0.81–7.01) | .11 |
School performance | 4.82 (2.11–11.01) | 2.95 (0.86–10.11) | .08 |
Free time | 3.11 (1.47–6.56) | 1.49 (0.50–4.40) | .46 |
Note. All missing observations were excluded from the analysis.
Statistically significant. Model was adjusted for age and gender.
Table 5.
Crude and adjusted odds ratios from multivariate analyses by suicide ideation
Variable | Crude OR (95% CI) | Adjusted OR (95% CI) | p |
---|---|---|---|
Gender: Female vs. male | 1.23 (0.78–1.92) | 1.37 (0.72–2.61) | .32 |
Sexual abuse/familial history | 2.64 (1.51–4.60) | 2.79 (1.25–6.20) | .01** |
Physical abuse/familial history | 1.69 (1.04–2.75) | 1.09 (0.55–2.16) | .78 |
Depression | 1.21 (0.49–2.97) | 0.71 (0.14–3.40) | .66 |
Other mental health problems | 3.11 (1.91–5.05) | 3.19 (1.64–6.18) | .01** |
Ever think of hurting others | 2.53 (1.60–4.00) | 1.50 (0.78–2.89) | .22 |
Think killing self will solve problems | 2.53 (1.47–4.36) | 1.51 (0.69–3.32) | .30 |
Tried to hurt self in the past | 6.96 (4.07–11.89) | 4.20 (2.08–8.48) | <.01** |
Can easily obtain means to kill self | 4.03 (2.45–6.65) | 3.51 (1.75–7.03) | <.01** |
Substance use | 2.33 (0.95–5.72) | 0.80 (0.20–3.17) | .75 |
Difficulty managing anger | 2.99 (1.46–6.11) | 1.46 (0.53–4.04) | .46 |
Religious affiliation | 0.75 (0.34–1.66) | 0.60 (0.20–1.79) | .36 |
School performance | 3.06 (1.35–6.92) | 1.97 (0.55–7.04) | .29 |
Free time | 2.16 (1.02–4.55) | 1.09 (0.32–3.63) | .88 |
Note. All missing observations were excluded from the analysis.
Statistically significant. The model was adjusted for age and gender. Adjusted model includes variables of primary interest, those that were significant in crude analysis and potential confounders.
Suicide Attempt
A history of having violent thoughts toward others (OR = 2.21, 95% CI = 1.04–4.72), as well as having mental health problems other than a depression diagnosis (OR = 3.34, 95% CI = 1.53–7.31) were positively associated with suicide attempts (Table 4). Adolescents who had a history of self-violence had a 4-fold increased odds of reporting suicide attempt (OR = 4.02; 95% CI = 1.87–8.59). History of sexual abuse was also significantly associated with suicidal attempt (OR = 2.43; 95% CI = 1.05–5.61).
Suicide Ideation
Having emotional/mental health issues increased the odds of ideation 3-fold (OR = 3.19, 95% CI = 1.64–6.18). Adolescents who had tried to hurt themselves in the past (OR = 4.20, 95% CI = 2.08–8.48), and those who felt they could easily obtain means to kill themselves if they wanted (OR = 3.51, 95% CI = 1.75–7.03), were significantly more likely to experience suicidal thoughts (Table 5). Adolescents who had a family or individual history of sexual abuse had over 2-fold increased odds of suicide ideation (OR = 2.79, 95% CI = 1.25–6.20).
Discussion
Our findings suggest that suicide attempts (25%) and suicide ideations (38%) among adolescents in our sample are quite high since approximately a quarter of the participants had attempted suicide, and over a third had thought of committing suicide. Given that attempts at suicide are some 10–40 times more common than the completed act (Bertolote et al., 2005; Platt et al., 1992; Schmidtke, Bille-Brake, De Leo, & Kerkhof, 2004), and that attempt constitutes a risk factor for completing suicides, this finding calls for reflecting on factors that may be associated with attempts at suicides, especially when these rates are compared to rates in other developing countries. Our study corroborates a similar study conducted in the United States among adolescents of different races including adolescents from the Caribbean, which found that attempted suicide was highest among Caribbean females (Joe, Baser, Neighbors, Caldwell, & Jackson, 2009). This is contrary to data from the WHO, which show a relatively low suicide rate in Jamaica and other Caribbean nations (WHO, 2003). However, it lends credence to a study by Joseph et al. (2003), who demonstrated that suicide rates in developing countries are grossly underreported.
The relatively high proportion of respondents who reported sexual abuse (32%) and physical abuse (24%) may provide some insight into why the suicide attempt rate is relatively high since abuse (physical or sexual) has been found to increase the risk of suicide 2-fold (Blum et al., 2003). Compared to a study of adolescents conducted in the Anglo-Caribbean region, which reported rates of 10% for sexual abuse and 16% for physical abuse (Halcon et al., 2003), these rates are high. They are, however, closer to those found in the United States, where sexual abuse rates among adolescents range between 15%–25% in the general population (Leserman, 2005). Because corporal punishment is still common place in most Caribbean countries (Fernald & Meeks, 1997; Levav, Guerrero, Phebo, Coe, & Cerqueira, 1996), the rate of physical abuse is not surprising, though further research is required to elucidate the reason for the high rate of sexual abuse. In this study, there was no significant association between suicidal behavior and female gender. However, sexual abuse was associated with both suicidal ideation and attempt. Studies have shown that girls who are sexually abused as children have a higher predilection to attempting or committing suicide (Roy & Janel, 2006). The higher rates of suicide attempts observed in our study may be explained by inadequate or discriminatory social support systems and fewer opportunities for psychotherapy for these victims of abuse in Jamaica compared to developed countries like the United States.
38% of the participants indicated having suicidal ideation, which is slightly higher than the estimates reported from other developing countries (Anteghini et al., 2001; Chan et al., 2008). Having emotional/mental health problems was associated with a 3-fold increase in the odds of exhibiting suicidal behavior. This is not unexpected because many studies have shown that up to 90%–98% of individuals who end up committing suicide had a depressive or psychiatric disorder (Bertolote & Fleischmann, 2002). Having access to lethal substances/objects with which to harm oneself was unsurprisingly, associated with a 3.5-fold increase in the odds of suicidal ideation. Programs in countries like Denmark have shown how precluding access to these weapons including the use of substances such as barbiturates decreases the incidence of suicides (Nordentoft, 2007).
Contrary to our expectations, substance abuse was not significantly associated with either suicide attempt or ideation. However, the low percentage of frequent substance use in both groups, where only about 6% reported monthly or more frequent use of alcohol and about 2% reported other substance use, is consistent with results from the 9-country Caribbean Youth Health Survey (Halcon et al., 2003). The survey reported monthly or more frequent alcohol use as 3.9% among females and 7.9% among males, and 1.2% (females) and 2.3% (males) reported other substance use (Halcon et al., 2003). This is much lower than results from an American survey, in which frequent alcohol use was 13.8% and drug use 9.9% (Waldrop et al., 2007). Our numbers are surprisingly low despite anecdotal reports of high prevalences of substance use in Jamaica. This may due to underreporting by participants primarily because of fear of disclosure. Further studies employing biomarkers of chronic drug and alcohol abuse would be useful in validating self-reports.
Our inability to detect significant associations for some variables as observed in similar studies could be attributed to our relatively small sample size. This provided limited statistical power to detect associations that were small and moderate in magnitude, and yielded some estimates that lacked precision. Another potential limitation of this study is the cross-sectional study design, which inherently makes it difficult to separate cause from effect, the measurement of exposure and disease being conducted at the same point in time. However, the study provides a framework to theorize on relationships between the variables measured. This design was useful in gathering preliminary data on suicidal behavior among adolescents in the study location and assessing risk factors for suicide in the population. However, cross-sectional studies are prone to bias. For example, questions about use of alcohol and ganga relied on self-reports (Subramanian, Subramanyam, Selvaraj, & Kawachi, 2008), which are known to be subject to recall bias (Hassan, 2006) and social desirability (Bertolote & Fleischmann, 2002). Nevertheless, the consistency of the associations we found and similar results across studies in different settings points to the validity of the results.
In conclusion, the study found that a significant proportion of adolescent participants living in the parishes of St. James and Westmoreland, Jamaica, had experienced suicide ideation and suicide attempts. Our findings provide a platform for further surveys with larger sample sizes comprising a better representation of adolescents from all 14 parishes of Jamaica to investigate the actual prevalence of mental disorders, suicide ideation, and suicide attempts in Jamaica. Data from these surveys could prove beneficial to other similar Caribbean countries as well. An accurate understanding of the prevailing risk factors should promote a more sympathetic approach to individuals, encourage government, nongovernmental, and community-based organizations to initiate support programs that could reduce stigma and promote free discussion. This may ultimately set the stage for the provision of more services for evaluation and management of adolescents with psychiatric disorders, provide psychotherapy for victims of physical or sexual abuse, and hopefully reduce the rates of suicide in Jamaica.
Acknowledgments
We thank Ms. Kamara Savage, who performed the data collection for this study. We are grateful to the health officials of the Western Regional Health Authority for their kind assistance in conducting the project. We also acknowledge Dr. Nelly Yatich and Ms. Patricia Bessler for their logistical and research support. This study was supported by Grant #T37 MD001448 from the National Center on Minority Health and Health Disparities, National Institutes of Health, USA. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
Biographies
Omobolawa Kukoyi is a Senior Research Assistant at Penn State University College of Medicine, Hershey, PA, USA. At the time of this publication, she was a graduate student in the Department of Epidemiology, UAB School of Public Health, Birmingham, AL, USA.
Dr. Faisal Shuaib is a Research Associate in the Division of Preventive Medicine, University of Alabama at Birmingham, AL, USA. At the time of this publication, he was a doctoral student in the Department of Epidemiology, UAB School of Public Health, Birmingham, AL, USA.
Dr. Sheila Campbell-Forrester is the Chief Medical Officer of the Ministry of Health, Jamaica. She has served as the Vice-President of the International Association of Adolescent Health and is a technical advisor to several international organizations.
Dr. Lisabeth Crossman is a Consultant Psychiatrist in the Department of Psychiatry, Cornwall Regional Hospital, Montego Bay, Jamaica.
Dr. Pauline Jolly, PhD, MPH, is a professor in the Department of Epidemiology, UAB School of Public Health, Birmingham, AL, USA. She is also the Director of the Minority Health International Research Training Program.
References
- Anteghini M, Fonseca H, Ireland M, Blum R. Health risk behaviors and associated risk and protective factors among Brazilian adolescents in Santos, Brazil. Journal of Adolescent Health. 2001;28:295–302. doi: 10.1016/s1054-139x(00)00197-x. [DOI] [PubMed] [Google Scholar]
- Beautrais AL. Risk factors for suicide and attempted suicide among young people. Australian and New Zealand Journal of Psychiatry. 2000;34:420–436. doi: 10.1080/j.1440-1614.2000.00691.x. [DOI] [PubMed] [Google Scholar]
- Bertolote JM, Fleischmann A. Suicide and psychiatric diagnosis: A worldwide perspective. World Psychiatry. 2002;1:181–185. [PMC free article] [PubMed] [Google Scholar]
- Bertolote JM, Fleischmann A, De Leo D, Bolhari J, Botega N, De Silva D, Wasserman D. Suicide attempts, plans and ideation in culturally diverse sites: The WHO SUPREMISS community survey. Psychological Medicine. 2005;35:1457–1465. doi: 10.1017/S0033291705005404. [DOI] [PubMed] [Google Scholar]
- Blum R, Halcon L, Beuhring T, Pate E, Campbell-Forrester S, Venema A. Adolescent health in the Caribbean: Risk and protective factors. American Journal of Public Health. 2003;93:456–460. doi: 10.2105/ajph.93.3.456. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Centers for Disease Control and Prevention (CDC) Youth risk behavior surveillance – United States 2001. MMWR Surveillance Summaries. 2002;51(SS04):1–64. [PubMed] [Google Scholar]
- Centers for Disease Control and Prevention (CDC) Youth risk behavior surveillance – United States 2007. MMWR Surveillance Summaries. 2008;57(SS04):1–131. [PubMed] [Google Scholar]
- Centers for Disease Control and Prevention (CDC) Youth suicide. 2009 Available at http://www.cdc.gov/ncipc/dvp/suicide/youthsuicide.htm.
- Chan W, Law C, Liu K, Wong PW, Law YW, Yip PS. Suicidality in Chinese adolescents in Hong Kong: The role of family and cultural influences. Social Psychiatry and Psychiatric Epidemiology. 2008;44:278–284. doi: 10.1007/s00127-008-0434-x. [DOI] [PubMed] [Google Scholar]
- Fergusson DM, Woodward LJ, Horwood LJ. Risk factors and life processes associated with the onset of suicidal behavior during adolescence and early adulthood. Psychological Medicine. 2000;30:23–39. doi: 10.1017/s003329179900135x. [DOI] [PubMed] [Google Scholar]
- Fernald LC, Meeks GJ. Aggressive behavior in children and adolescents. Part II: A review of the effects of environmental characteristics. West Indian Medical Journal. 1997;46:104–106. [PubMed] [Google Scholar]
- Halcon L, Blum R, Beuhring T, Pate E, Campbell-Forrester S, Venema A. Adolescent health in the Caribbean: A regional portrait. American Journal of Public Health. 2003;93:1851–1857. doi: 10.2105/ajph.93.11.1851. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hassan E. Recall bias can be a threat to retrospective and prospective research designs. Internet Journal of Epidemiology. 2006;3(2) Available from http://www.ispub.com/ostia/index.php?xmlFilePath)journals/ije/vol3n2/bias.xml. [Google Scholar]
- Jamaica Information Service. Mental health week focuses on suicide. 2006 Available at http://www.jis.gov.jm/health/html/20061011t110000–0500_10264_jis_mental_health_week_focuses_on_suicide.asp.
- Jamaican Ministry of Health. Ministry of Health annual report, 2001. Kingston: Author; 2001. [Google Scholar]
- Joe S, Baser RS, Neighbors HW, Caldwell CH, Jackson JS. 12-Month and lifetime prevalence of suicide attempts among Black adolescents in the national survey of American life. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48:271–282. doi: 10.1097/CHI.0b013e318195bccf. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Joseph A, Abraham S, Muliyil JP, George K, Prasad K, Minz S, Jacob KS. Evaluation of suicide rates in rural India using verbal autopsies, 1994–9. British Medical Journal. 2003;326:1121–1122. doi: 10.1136/bmj.326.7399.1121. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kelly TM, Cornelius JR, Lynch KG. Psychiatric and substance use disorders as risk factors for attempted suicide among adolescents: A case control study. Suicide and Life-Threatening Behavior. 2002;32:301–312. doi: 10.1521/suli.32.3.301.22168. [DOI] [PubMed] [Google Scholar]
- Lenth RV. Java applets for power and sample size [Computer software] 2006–9 Available from http://www.stat.uiowa.edu/~rlenth/Power.
- Leserman J. Sexual abuse history: Prevalence, health effects, mediators, and psychological treatment. Psychosomatic Medicine. 2005;67:906–915. doi: 10.1097/01.psy.0000188405.54425.20. [DOI] [PubMed] [Google Scholar]
- Levav I, Guerrero R, Phebo L, Coe G, Cerqueira MT. Reducing corporal punishment for children: A call for a regional effort. Bulletin of the Pan American Health Organization. 1996;30(1):70–79. [PubMed] [Google Scholar]
- Li XY, Phillips MR, Zhang YP, Xu D, Yang GH. Risk factors for suicide in China’s youth: A case control study. Psychological Medicine. 2008;38:397–406. doi: 10.1017/S0033291707001407. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Maris RW. Suicide. Lancet. 2002;360:319–326. doi: 10.1016/S0140-6736(02)09556-9. [DOI] [PubMed] [Google Scholar]
- Moscicki EK. Identification of suicide risk factors using epidemiologic studies. Psychiatric Clinics of North America. 1997;20:499–517. doi: 10.1016/s0193-953x(05)70327-0. [DOI] [PubMed] [Google Scholar]
- National Alliance on Mental Illness. Teenage suicide. 2008 Available at http://www.nami.org.
- Nordentoft M. Prevention of suicide and attempted suicide in Denmark. Epidemiological studies of suicide and intervention studies in selected risk groups. Danish Medical Bulletin. 2007;54:306–369. [PubMed] [Google Scholar]
- Pan American Health Organization. Press release: Mental disorders in Latin America and the Caribbean forecast to increase. 2005 Available at http://www.paho.org/english/dd/pin/pr051209.htm.
- Phillips MR, Li X, Zhang Y. Suicide rates in China, 1995–99. Lancet. 2002;359(9329):344. doi: 10.1016/S0140-6736(02)07954-0. [DOI] [PubMed] [Google Scholar]
- Platt S, Bille-Brahe U, Kerkhof A, Schmidtke A, Bjerke T, Crepet P, Sampaio-Faria J. Parasuicide in Europe: The WHO/EURO multicenter study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatrica Scandinavica. 1992;85:97–104. doi: 10.1111/j.1600-0447.1992.tb01451.x. [DOI] [PubMed] [Google Scholar]
- Reinherz HZ, Tanner JL, Berger SR, Beardslee WR, Fitzmaurice GM. Adolescent suicidal ideation as predictive of psychopathology, suicidal behavior, and compromised functioning at age 30. American Journal of Psychiatry. 2006;163:1226–1232. doi: 10.1176/ajp.2006.163.7.1226. [DOI] [PubMed] [Google Scholar]
- Roy A, Janel M. Gender in suicide attempt rates and childhood sexual abuse rates: Is there an interaction? Suicide & Life-Threatening Behavior. 2006;36:329–335. doi: 10.1521/suli.2006.36.3.329. [DOI] [PubMed] [Google Scholar]
- Schmidtke A, Bille-Brake U, De Leo D, Kerkhof A, editors. Suicidal behavior in Europe: Results from the WHO/EURO multicenter study on suicidal behavior. Göttingen: Hogrefe and Huber; 2004. [Google Scholar]
- Subramanian S, Subramanyam M, Selvaraj S, Kawachi I. Are self-reports of health and morbidities in developing countries misleading? Evidence from India. Social Science and Medicine. 2008;68:260–265. doi: 10.1016/j.socscimed.2008.10.017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Waldrop A, Hanson R, Resnick H, Kilpatrick DG, Naugle AE, Saunders BE. Risk factors for suicidal behavior among adolescents: Implication for prevention. Journal of Traumatic Stress. 2007;20:869–879. doi: 10.1002/jts.20291. [DOI] [PubMed] [Google Scholar]
- Wasserman D, Cheng Q, Jiang G. Global suicide rates among young people aged 15–19. World Psychiatry. 2005;4:114–120. [PMC free article] [PubMed] [Google Scholar]
- Western Regional Health Authority. Internal data. 2006 Provided February 16, 2006. [Google Scholar]
- World Health Organization (WHO) The second decade: Improving adolescent health and development. Geneva: Author; 2001. [Google Scholar]
- World Health Organization (WHO) World report on violence and health: Summary. Geneva: Author; 2002. [Google Scholar]
- World Health Organization (WHO) Suicide rates (per 100,000), by country, year, gender. 2003 Available at http://www.who.int/mental_health/prevention/suicide/suiciderates/en/