Suicidal ideation in college students having major depressive disorder: Role of childhood trauma, personality and dysfunctional attitudes
Introduction
Suicide is a major public health concern across the globe. According to the World Health Organization (WHO, 2019), suicide accounted for 1.3% of all deaths worldwide, and more than 700,000 people die by suicide every year, which is one person every 40 s. It is reported that suicide has been regarded as the second leading cause of death in the world of young people 15–29 years of age, especially in China, where the suicide rate among younger age groups has been on the rise (Lew et al., 2020).
College is a critical period in the transition from adolescence to adulthood. As the stress of the transition increases, so does the incidence of mental disorders (Hoying et al., 2020). Studies have shown that college students with major depressive disorder (MDD) present a higher prevalence of suicidal behavior because of the tense campus atmosphere and psychological stress (Demenech et al., 2021; Lew et al., 2019). Among those who attempt suicide, 34%–42% have had suicidal ideation (SI), indicating that SI is a strong risk factor for predicting suicide (A. T. Beck et al., 1988; G. Kim and Cha, 2018). Statistics have shown the prevalence of SI among college students worldwide ranges from 5.4 to 38% (Lew et al., 2019).
At present, a widely accepted explanation for the mechanism of suicide is the theory of stress-susceptibility proposed by Mann in his model (Mann et al., 1999). This theory holds that suicide is the result of a combination of susceptibility, stress and protection factors. Susceptibility factors include not only adverse personality traits such as neuroticism and psychoticism, but also cognitive distortion, which is defined as the presence of false, irrational, one-sided or paranoid components in cognition (Marton et al., 1993). Stress factors mainly refer to mental or psychological factors. Depression, has been shown to be a strong risk factor for suicide (T. Handley et al., 2018; Mann et al., 1999). Protective factors mainly arise from having a good family and social support. However, Mann's model doesn't interpret how these factors interact to predict suicide. The psychological stress theory suggests that stressors, mainly referring to negative events experienced early in life, cause stress responses through the mediation of psychosocial factors such as adverse personality traits, cognitive distortion, negative coping style and protective factors (Lazarus and Folkman, 1984). The individual's negative cognitive appraisal of stressors plays an important role in the development of psychological stress responses including depression, anxiety and other psychotic symptoms (Lazarus and Folkman, 1984). Therefore, SI may be the result of the interaction of multiple factors. Most studies only focus on the direct effects of influencing factors or the correlation between variables, but how they interact to predict SI remains unclear.
In recent years, there have been increasing reports of adverse childhood events in children and adolescents. Childhood trauma has become a major global public health issue (Zheng et al., 2020). In developed countries, about 16% of children experience physical abuse, and 10% experience neglect or psychological abuse each year (D. Wang et al., 2018). A recent meta-analysis reported the estimated prevalence of physical abuse, emotional abuse, sexual abuse and neglect among children under the age of 18 in China was 26.6%, 19.6%, 8.7%, and 26%, respectively (Fang et al., 2015). This trend is significantly associated with a higher risk of depression and suicidal behavior (Angelakis et al., 2020; Li et al., 2016). A study has shown that childhood trauma can explain 15% of suicidal tendencies (Fjeldsted et al., 2019). As a stressor, childhood trauma has a long-term impact on an individual's mental health. Adverse personality traits and cognitive distortion are more likely to be present in those who have experienced childhood trauma than in those who have not (Hovens et al., 2016; Lee and Song, 2017). Dysfunctional attitudes are an underlying distorted cognitive structure, and are defined as beliefs and attitudes that produce negative thoughts about self, others, and the future, which are predisposing factors for depression (Horiuchi et al., 2017). Given that, it is proposed that childhood trauma may have an indirect effect on SI via the multiple mediating effects of personality, dysfunctional attitudes and depressive symptoms (Hypothesis 1).
In the study of factors affecting suicide, the role of personality has received extensive attention (Brezo et al., 2006). Personality is a psychological trait and conscious disposition formed by genetic qualities and acquired social environment (Klein et al., 2011), which can reflect the attitude and evaluation of things (Laird et al., 2019). Beck's cognitive theory suggests the tendency to adopt too much negative evaluation and interpretation of things leads to dysfunctional attitudes, which are also determinants of the development of depression (A.T. Beck, 1967). Many studies have shown that college students with SI tend to show higher neuroticism, psychoticism and lower extroversion (Gao et al., 2003; Huang et al., 2019). Therefore, it is proposed that personality can predict SI directly and may have an indirect effect on SI via dysfunctional attitudes and depressive symptoms (Hypothesis 2).
The cognitive-behavioral theory of suicide suggests that patients with a high susceptibility to suicide tend to exhibit dysfunctional attitudes (A. T. Beck et al., 1993; Rudd, 2000). Dysfunctional attitudes reflect underlying depression schemas that promote information-processing errors with which depressed individuals filter or dampen the significance of positive information and exaggerate the meaning and importance of negative information (A. T. Beck et al., 1993). In a follow-up study of patients with MDD, dysfunctional attitudes were the most important risk factor, increasing rates of SI by 35% (T. E. Handley et al., 2016). Therefore, it is proposed hat dysfunctional attitudes are the facilitator of SI directly and these may have an indirect effect on SI via depressive symptoms (Hypothesis 3).
Based on Hypothesis 1, Hypothesis 2 and Hypothesis 3 as described above, the current research intends to construct a Structural Equation Model (SEM) to examine the effects of childhood trauma, personality, dysfunctional attitudes and depressive symptoms on SI. The proposed conceptual model is shown in Fig. 1. As far as the authors know, this is the first study to examine all of these factors on the outcome of SI.
Section snippets
Setting and participants
This was a cross-sectional study based on the Early-Warning System and Comprehensive Intervention for Depression (ESCID), that was conducted to explore the pathogenesis and recurrence mechanisms of MDD and intervention methods (Kang et al., 2021). A total of 2,306 patients who visited Renmin Hospital of Wuhan University from April 2019 to May 2020 were enrolled in the ESCID study. Two experienced psychiatrists confirmed the participants' diagnosis which met the Diagnostic and Statistical Manual
Sample characteristics and preliminary analyses
A total of 662 questionnaires were distributed; 565 questionnaires were returned and valid (effective response rate: 85.3%). Thus, 565 college students with MDD were enrolled in this study, with an average age of 22.29 ± 1.54 years, including 140 (24.78%) men and 425 (75.22%) women. A total of 373 (66.02%) patients had suicidal ideation (SI), and 192 (33.98%) did not. Among all participants, 149 (26.37%) experienced emotional abuse, 100 (17.70%) experienced physical abuse, 73 (12.92%)
Discussion
To the best of the researchers' knowledge, this is the first study which has attempted to explore the multiple effects of childhood trauma, personality, dysfunctional attitudes and depressive symptoms on suicidal ideation (SI). In this study, MDD patients with SI accounted for two-thirds of the total, and there were significant differences in their psychosocial factors. Depressive symptoms and personality can independently predict SI, while childhood trauma, personality and dysfunctional
Limitations
There are several limitations of this research. First, the study employed convenience sampling to collect data from a hospital in Wuhan, China, which may limit the generalizability of findings. Second, results of the current study may be biased due to the self-report nature of the data collection procedure, the number of research subjects and the differences in suicide risk assessment. Third, this is a cross-sectional survey, which means although the predictive variables of suicidal ideation
Conclusion
A total of 66.02% of the college students having MDD in the current study had suicidal ideation (SI). There were significant differences in physical abuse, emotional abuse, physical neglect, emotional neglect, psychoticism, neuroticism, extroversion, dysfunctional attitudes and depressive symptoms in the students with SI compared with those without. The factors of childhood trauma, personality and dysfunctional attitudes affect SI through chain mediation. In addition, depressive symptoms and
CRediT authorship contribution statement
Si Chen Zhou, Dan Luo, Xiao Qin Wang, Junyong Zhu contributed equally to the work. Si Chen Zhou, Dan Luo, Qian Liu designed the study and wrote the research protocol. Si Chen Zhou, Dan Luo, Xiao Qin Wang, Junyong Zhu, Shuqin Wu, Ting Sun, Xin Yi Li, Lijun Kang, Simeng Ma, Baili Lu, Qian Liu, Bing Xiang Yang, Zhongchun Liu did the literature review, managed the field survey, quality control, and statistical analysis and prepared the manuscript draft. Qian Liu, Bing Xiang Yang, Zhongchun Liu,Dan
Conflict of Interest
The authors report no actual or potential conflicts of interest.
Sources of funding
This work was supported by grants from the National Natural Science Foundation of China (grant number: 72174152), the National Key R&D Program of China (grant number: 2018YFC1314600), and the Fundamental Research Funds for the Central Universities (grant numbers: 2042022kf1218; 2042022kf1037).
Acknowledgments
Sincere thanks are given to Dr. Sharon R. Redding (EdD, RN, CNE) for assistance in editing.
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These authors contributed equally to this work and share first authorship.