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. Author manuscript; available in PMC: 2020 Feb 1.
Published in final edited form as: Psychol Trauma. 2018 May 7;11(2):184–188. doi: 10.1037/tra0000365

Suicidal ideation among adolescents following natural disaster: The role of prior interpersonal violence

Kelly L Zuromski 1,2, Heidi Resnick 1, Matthew Price 3, Sandro Galea 4, Dean G Kilpatrick 1, Kenneth Ruggiero 5
PMCID: PMC6222023  NIHMSID: NIHMS962781  PMID: 29733669

Abstract

Objective

The current study examined variables, including prior traumatic events, disaster exposure, and current mental health symptomatology, associated with suicidal ideation following experience of a natural disaster.

Method

Utilizing a sample of 2000 adolescents exposed to the Spring 2011 tornadoes in the areas surrounding Tuscaloosa, AL and Joplin, MO, we hypothesized that prior interpersonal violence (IPV), more so than other prior traumatic events or other symptoms, would be associated with suicidal ideation post-disaster.

Results

Suicidal ideation was reported by approximately 5% of the sample. Results of binary logistic regression were consistent with hypotheses in that prior IPV exposure emerged as the variable most robustly related to presence of post-disaster suicidal ideation, even accounting for current symptoms (i.e., PTSD and depression). Moreover, neither prior accident nor prior natural disaster exposure was significantly associated with post-disaster suicidal ideation, suggesting that something specific to IPV may be conferring risk for suicidality. No other variables, including disaster exposure variables or demographic characteristics, emerged as significantly related.

Conclusions

Our results suggest that individuals who have a history of IPV may be particularly vulnerable following experience of additional traumatic events and that for suicide risk, the experience of prior IPV may be more relevant to consider in the aftermath of natural disasters beyond variables related to the index trauma or current symptomatology.

Keywords: natural disaster, suicide, interpersonal violence, risk factor

Suicide is the second most common cause of death among adolescents and young adults (ages 10-24) (CDC, 2014), highlighting the continued need to identify and understand risk factors for suicidal behavior (i.e., suicidal ideation, plans, and attempts). Traumatic event exposure has been studied as one risk factor related to adolescent suicide risk (e.g., De Wilde & Kienhorst, 1992; Waldrop et al., 2007), and in particular, natural disasters have been shown to increase mental health symptoms (e.g., Major Depressive Disorder [MDD], posttraumatic stress disorder [PTSD]; Furr et al., 2010; Norris et al., 2002), that are related to risk for suicide. Limited research has directly explored the relationship between suicidal behavior following natural disasters (see Kõlves et al., 2013 for review). Moreover, most of this research has been conducted among adults, though research has suggested that developmentally, children and adolescents may be particularly vulnerable and less able to cope with the impact of disasters (Pfefferbaum et al., 2014).

Notably absent from existing literature is consideration of how prior traumatic event exposure may influence suicidal behavior in the aftermath of a natural disaster. However, a number of studies have demonstrated that cumulative or prior trauma history—particularly, traumas involving interpersonal violence (e.g., physical assault, witnessed violence; Hedtke et al., 2008)—tends to yield worse subsequent mental health outcomes among both adolescents and adults (e.g., Breslau et al., 1999; Copeland et al., 2007; Nishith et al., 2000). As such, it may be that presence of prior traumatic event exposure is also important to consider in predicting suicidal behavior following natural disaster. This limitation in the literature may be especially relevant to consider, given robust links that have been found between some types of traumatic events—namely, those involving interpersonal violence—and suicide during adolescence (Brent et al., 1999). Thus, failing to account for the effect of these prior traumas may obscure understanding of the impact of subsequent traumatic events on risk for suicide.

The goal of the current report was to examine the relationship between prior traumatic events and suicidal behavior following experience of a natural disaster among adolescents, utilizing data collected in the aftermath of the Spring 2011 tornadoes in Joplin, Missouri and Tuscaloosa, AL. We sought to investigate whether prior experience of traumatic events, and specifically, prior interpersonal violence (IPV) was related to likelihood of suicidal ideation and/or self-harm ideation (henceforth suicidal ideation) post-disaster, while controlling for disaster exposure variables (e.g., injury sustained), and presence of mental health symptoms. As an exploratory goal of this paper, we also sought to investigate the prevalence of suicidal ideation following a tornado, given the literature examining suicidality following this type of natural disaster is limited, and that certain features of tornadoes (e.g., lack of warning time and also whether people will receive these warnings (Simmons & Sutter, 2012), may lend to unique risk for those exposed to tornadoes compared to other natural disasters.

Methods

Procedure and participants

The final sample utilized in the current study consisted of 2,000 families with adolescents (12- to 17-year-olds) identified1 as living in areas affected by tornadoes occurring in and surrounding Tuscaloosa, Alabama on April 25–28, and in Joplin, Missouri on May 22, 2011. Eligible families were residing at their address at the time of the tornado and had both an adolescent aged 12 to 17 years and a legal guardian present in the home. Eligible adolescent-parent dyads each provided informed consent, and then separately completed several structured standardized computer-assisted telephone interviews by trained professional interviewers. Telephone interviews averaged approximately 25 minutes in length and occurred, on average, 8.7 months after tornado exposure (SD = 2.6; range = 4–13.5; conducted between 9/2011 and 6/2012). Of those screened, 61% were included in the study. Families received $15 for completing the baseline interview.

The final sample consisted of 2,000 adolescents whose mean age was 15 years (SD = 1.73). Approximately half of participants were girls (51.00%, n = 1019), and were predominantly White (n = 1251, 62.50%); 22.60% Black/African-American (n = 451), 3.80% Other race (n = 75), and 11.10% unknown/did not specify race/ethnicity (n = 223). The majority of participants reported family income above $20,000 (69.10%, n = 1383). Our data were weighted to adjust for discrepancies in demographics (i.e., age, race, gender) between the sample and the regions from which they recruited using US Census data. For a more comprehensive description of study procedures, refer to Adams et al., 2014 and Ruggiero et al. 2015.

Measures

Suicidal ideation

Adolescents were asked to report whether they had experienced suicidal ideation and/or self-harm ideation since the tornado with the one dichotomous question (i.e., Since the tornado, has there been a time of two weeks or longer when you felt things were so bad that you thought about hurting yourself or thought you would be better off dead?).

PTSD and MDD symptoms

Adolescent PTSD and MDD was measured using a structured interview assessing for presence of each DSM-IV symptom of PTSD and MDD. This interview has been previously used and psychometrically validated in the National Survey of Adolescents and other large-scale epidemiologic surveys developed by our team (e.g., Kilpatrick et al., 2003; Resnick et al., 1993). Participants who endorsed lifetime symptoms were asked to indicate whether they had experienced a given symptom since the tornado. A total score for number of symptoms experienced since the tornado was created for use in analyses (α = .87 and .78 for PTSD and MDD, respectively). Our outcome variable (i.e., suicidal ideation) was included in the MDD interview; thus, the total scores for MDD excluded this item. For descriptive purposes, we also used symptom endorsement since the tornado to determine whether adolescents currently met full DSM-IV criteria for PTSD and MDD, which included assessment of whether functional impairment was present.

Prior exposure to interpersonal violence (IPV)

Prior exposure to IPV was assessed across three domains: direct physical/aggravated assault, witnessed family interpersonal violence, and witnessed community interpersonal violence. Three questions were used to assess for prior IPV exposure in these areas (i.e., Have you ever been beaten up, hit, punched, shot at, or threatened to be hurt badly?, Have you ever seen a family member being hit, punched, or kicked very hard at home, not including ordinary fights between brothers and sisters?, and Have you ever seen someone in your town being beaten up, shot at, or killed?). Responses to these IPV questions were used to create a dichotomous variable indicating whether adolescents had ever experienced any prior IPV.

Prior exposure to other traumatic events

Adolescents were asked two dichotomous questions on whether they had previously experienced of any prior natural disaster (e.g., hurricane, flood) or accident (e.g., car accident, fire).

Disaster exposure variables

Three primary disaster exposure variables were included in the current analyses based on prior findings (i.e., Adams et al., 2014). Dichotomous variables assessed whether caregivers sustained any physical injuries during the tornado, and also whether they were concerned about the safety of loved ones during the tornado. The total number of services (e.g., water, electricity) lost for more than a week after the tornado was also assessed and used as a predictor variable in analyses (Cronbach’s α = 0.67).

Statistical Procedure

Missing data and non-normality

Missing data were handled using full information maximum likelihood and using a robust maximum likelihood estimator (MLR). Missing data were minimal; minimum covariance coverage ranged from .83 to 1.00. Analyses were conducted in Mplus version 7.4 and SPSS Version 21.

Results

Predictors of Post-Disaster Suicidal Ideation

Descriptive statistics on study variables can be found in Table 1. A relatively small proportion of the sample endorsed experiencing suicidal ideation since the tornado (5.30%; n = 105), while proportions of participants meeting PTSD and MDD diagnoses since the tornado were 6.40% (n = 129) and 7.40% (n = 149), respectively. Binary logistic regression was utilized to investigate which variables were associated with suicidal ideation post-disaster, with all variables entered into the model simultaneously (Table 2). As shown in Table 2, few variables emerged as significantly associated with suicidal ideation. PTSD symptoms were associated with presence of suicidal ideation (b = .11, p < .05; OR = 1.12, 95% CI [1.03, 1.22]), indicating that suicidal ideation is more likely among adolescents experiencing more PTSD symptoms. Similar results were found for symptoms of MDD (b = .52, p < .001; OR = 1.68, 95% CI [1.42, 1.98]), demonstrating that experience of more MDD symptoms is positively associated with presence of suicidal ideation. Finally, history of IPV exposure was more robustly related to suicidal ideation compared to PTSD and MDD symptoms, such that the odds of endorsing suicidal ideation were nearly two and half times larger for those with IPV history than for those without (b = .885, p < .01; OR = 2.42, 95% CI [1.37, 4.30]).

Table 1.

Descriptive statistics on study variables (N = 2000).

Variable % endorsing (n) Mean SD Range
Physical Injury 2.70 (53) – – –
Concern about others 74.80 (1495) – – –
Loss of services – .56 1.10 0-7
Prior disaster 26.70 (534) – – –
Prior accident 25.70 (514) – – –
Prior IPV 36.40 (729) – – –
PTSD symptoms – 2.40 3.30 0-17
MDD symptoms – 1.25 1.80 0-8
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Note. IPV = interpersonal violence. PTSD and MDD symptoms refers to total symptom count.

Table 2.

Results of logistic regression predicting presence of suicidal ideation since tornado 95% Confidence Interval

b SE p Odds Ratio Lower Upper
Gender −0.48 0.28 0.09 0.62 0.36 1.08
Black/African-American −0.22 0.37 0.54 0.80 0.39 1.64
Other race 0.51 0.44 0.25 1.67 0.70 3.96
Income 0.00 0.32 0.99 1.00 0.53 1.88
Age −0.01 0.08 0.88 0.99 0.85 1.15
Physical Injury 0.03 0.64 0.96 1.03 0.30 3.58
Concern about others −0.26 0.31 0.40 0.77 0.42 1.41
Loss of services −0.12 0.14 0.37 0.89 0.68 1.16
PTSD symptoms 0.11 0.04 0.01 1.12 1.03 1.22
MDD symptoms 0.52 0.09 < .001 1.68 1.42 1.99
Prior disaster 0.18 0.29 0.54 1.20 0.68 2.11
Prior accident 0.30 0.28 0.29 1.34 0.78 2.32
Prior IPV 0.87 0.29 < .01 2.40 1.35 4.26
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Note. Gender coded 0 = female, 1 = male. For Black/African-American and Other race variables, White race was used as the reference variable (i.e., Black/African-American was coded 0 = White or Other Race, 1 = Black/African-American.; Other race coded 0 = White or Black/African-American, Other race = 1). Income coded 0 = under $20,000, 1 = over $20,000. Physical injury, concern about others, prior disaster, prior accident, and prior IPV are coded 0 = absent, 1 = present. PTSD symptoms = Posttraumatic Stress Disorder symptoms since tornado; MDD symptoms = Major Depressive Disorder symptoms since tornado. IPV = interpersonal violence.

Additional Descriptive Results on Prevalence of Suicidal Ideation

Additional descriptive analyses were conducted to examine the prevalence of suicidal ideation among adolescents endorsing a history of IPV. Prevalence of suicidal ideation since the tornadoes was significantly higher among those reporting history of IPV versus those who did not report IPV history (11.30% vs. 1.80%), χ2(1, N = 1977) = 81.93, p < .001.

Additionally, descriptive analyses on the prevalence of suicidal ideation among those with PTSD and MDD diagnoses were conducted, given these symptoms emerged as significantly related to suicidal ideation in regression analyses. Among those meeting criteria for PTSD since the tornado, prevalence of suicidal ideation was higher than for those not meeting criteria (33.10% vs. 3.30%), χ2(1, N = 1927) = 212.02, p < .001. The same was true of those meeting criteria for MDD since the tornado, as 46.30% endorsed suicidal ideation compared to 2.00% of those not meeting MDD criteria, χ2(1, N = 1986) = 532.18, p < .001.

Discussion

Consistent with our hypotheses, prior IPV exposure emerged as the variable most robustly related to post-disaster suicidal ideation among adolescents exposed to the Spring 2011 tornadoes, while accounting for other risk factors. On the contrary, neither prior accident nor prior natural disaster exposure was significantly associated with post-disaster suicidal ideation, suggesting that something specific to IPV may be conferring risk for suicidality. Of note, this observed relationship between IPV and suicidal ideation was significant while also including and accounting for other salient risk factors for suicidal behavior in the model. Namely, both PTSD and MDD symptoms since the tornado were also positively associated with suicidal ideation, but to a lesser degree than was IPV. Finally, no other variables, including disaster exposure variables or demographic characteristics, emerged as significantly related. Thus, our results suggest that for suicide risk, experience of prior IPV may be more relevant to consider in the aftermath of natural disasters, beyond variables related to the index trauma or post-disaster symptomatology, consistent with past research indicating the significant relationship between IPV and suicide (e.g., MacIsaac et al., 2017; Stein et al., 2010). Future research is needed to better understand mechanisms underlying this relationship.

As a secondary goal of the current paper, we also sought to examine the prevalence of suicidal ideation post-tornado. We found that suicidal ideation was endorsed by about 5% of our sample, which is generally lower than prevalence of ideation reported in other samples (e.g., 17% during a one year period among a population-based sample of high schoolers; Kann et al., 2013). Though the lower prevalence of ideation in our study was potentially affected by geographic or methodological differences, this finding highlights the general resiliency of our sample, which is consistent with research suggesting that a drop in suicidal behavior actually occurs immediately following a natural disaster (e.g., Kessler et al., 2006; Kõlves et al., 2013).

Several aspects of the current study could be improved upon in future research. Our study was cross-sectional and limited demographically; future work should seek to replicate these findings in more diverse, longitudinal samples, which ideally would also include measurement of symptoms prior to experience of a traumatic event to account for these effects. We also note several measurement limitations. Our measure of suicidal ideation was dichotomous, and also conflated assessment of potential non-suicidal self-harm ideation, which does not allow for more nuanced analyses that may be conducted when using a more comprehensive measure that assesses for several facets of suicidal ideation specifically (e.g., duration, frequency). Additionally, our measure of IPV aggregated exposure to direct or witnessed physical assault, and did not include other IPVs such as sexual assault. Future work should consider incorporation of more comprehensive measures of both suicidal ideation and IPV.

The current study demonstrates the importance of IPV in the development of mental health symptomatology, including suicidal behavior. Our results also highlight that even in the aftermath of another traumatic event (i.e., natural disaster), IPV appears to be more robustly associated with suicidal ideation than are variables related to current mental health symptoms or related to the index trauma, suggesting individuals who have a history of IPV may be particularly vulnerable following experience of additional traumatic events.

Clinical Impact Statement.

People often experience mental health symptoms, including suicidal thoughts, after experiencing traumatic events. The current study aimed to explore what predicts presence of these problems following a natural disaster. We found that participants who had experienced interpersonal violence some time in their lives were more likely to have suicidal ideation after a natural disaster, and that this interpersonal violence was more strongly related to ideation than any other variable in our model (e.g., depression, PTSD). In the aftermath of disasters, assessment of prior trauma—and particularly, interpersonal violence—may inform identification and treatment of those at increased suicide risk.

Acknowledgments

The National Institutes of Health Grants R01-MH081056 and MH107641 (KJR), T32-MH018869 sponsoring KLZ, and MH107641-02S1 supporting efforts of HR. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or other agencies.

Footnotes

The authors declare that they have no potential or competing conflicts of interest.

1

Families affected by the tornadoes were identified using latitude/longitude coordinates of the tornado tracks, which were obtained from NOAA tornado track incident reports (National Oceanic & Atmospheric Administration, 2011).

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