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The association between psychological strain and suicidal behaviors among college students: A mental health survey in Jilin Province, Northeast China
Journal of Affective Disorders 259 (2019) 195–200
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Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research paper
The association between psychological strain and suicidal behaviors among college students: A mental health survey in Jilin Province, Northeast China
T
Song Yana, Bai Weia, Wang Mohana, Liu Xinyua, Zhang Lilia, Yu Weiyinga, Li Yuanyuana, ⁎ Hua Wanqinga, Lew Bobb, Talib Mansor Abuc, Kou Changguia, a
Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, No. 1163 Xinmin Street, Changchun, Jilin 130021, China Department of Social Psychology, Putra University of Malaysia, Malaysia c Department of Human Development and Family Study, Putra University of Malaysia, Malaysia b
A R T I C LE I N FO
A B S T R A C T
Keywords: Psychological strain Suicide Mental health
Background: Suicide is a major global mental health problem among college students. The aim of the current study was to explore the association between the psychological strains of the strain theory of suicide and suicidal behaviors among college students. Methods: Participants comprised 1912 college students (16–28 years old, 47.2% female) from three universities in Jilin Province, China, who completed the self-report assessments of psychological strains (40 items Psychological Strains Scale) and suicidal behaviors (Suicidal Behaviors Questionnaire-Revised). The demographic characteristics included four variables: health status, psychological status, academic status and economic status. Results: Approximately 15.0% (286/1912) of participants were classified as having suicide risk, based on the cut-off scores of the SBQ-R. The prevalence of suicidal behaviors among males and females was 11.9% (120/ 1009) and 18.4% (166/903), respectively. Value strain (OR = 1.075, 95%CI: 1.057–1.094), aspiration strain (OR = 1.082, 95%CI: 1.064–1.101), deprivation strain (OR = 1.073, 95%CI: 1.052–1.093), and coping strain (OR = 1.095, 95%CI: 1.075–1.116) were risk factors for suicidality in college students. Coping strain (OR = 1.050, 95%CI: 1.023–1.077) was still positively associated with suicide risk in multivariate logistic regression. Logistic regression analysis indicated that coping strain had the highest correlation with suicidal behaviors. Limitations: The directionality of the relationships cannot be deduced because this study is cross-sectional. Conclusion: This study confirms a strong association between psychological strains and suicidal behaviors in college students. Some measures can be taken to reduce psychological strains to mitigate suicide risk among college students. More studies investigating coping strain among college students are warranted.
1. Introduction Suicide, the most tragic outcome, is the second-leading cause of death in young adults as well as in college students (MendezBustos et al., 2013). According to the World Health Organization (WHO), the number of people who die of suicide is nearly 1 million worldwide per year, and it is estimated that this figure will reach 1.5 million by 2020 (Aloba et al., 2017). Suicide has become a major public health issue. A review of suicidal ideation among Chinese college students showed that the overall pooled prevalence was 11.1% and ranged from 4.9% to 35.6% (Li et al., 2014). Substantial research has focused on common suicidal thoughts and behaviors (e.g., ideation, plans, and/
⁎
or attempts) in college students to advance appropriate prevention and intervention work (Holdaway et al., 2018; Wilcox et al., 2010). For example, in a survey of approximately 1700 college students, it was reported that 32.2% of them had brief passing thoughts of suicidal ideation and 4.7% had suicidal plans at least once and truly had intentions to die (Becker et al., 2018). Based on these previous studies, this study examined a comprehensive set of measures, including previous ideation or attempts, ideation frequency, communication with someone with suicidal intentions, and future likelihood of suicide attempts, in a sample of 1912 college students. The strain theory of suicide is a sociopsychological theoretical framework on suicidality that was first conceptualized by Zhang J in 2005.
Corresponding author. E-mail address: [email protected] (C. Kou).
https://doi.org/10.1016/j.jad.2019.08.042 Received 27 January 2019; Received in revised form 5 July 2019; Accepted 17 August 2019 Available online 19 August 2019 0165-0327/ © 2019 Published by Elsevier B.V.
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(Zhai et al., 2015). Against this background, the present study had two objectives. First, we described demographic characteristics and the prevalence of suicidal behaviors in a sample of college students. Second, we explored the unique association between psychological strains and suicidal behaviors.
It explained the unique patterns of rural suicide victims in China (Zhang, 2005). The strain theory of suicide assumes that strains caused by psychological stress or frustration in an individual's life usually precede suicidal behaviors (Zhang et al., 2010). A psychological strain consists of at least two opposite pressures or social experiences in a person's daily life, and this experience will generate strain when he or she experiences extremely conflicting thoughts or experiences. Psychological strains encompass four types: value strain, aspiration strain, deprivation strain, and coping strain. Each strain can be derived from specific sources. Psychological strains can be attributed to different sources. The first source is differential value conflicts, in which the individual experiences value strain when he or she recognizes equally important but conflicting values or beliefs competing in his or her daily life. The second source of strain is a discrepancy between aspiration and reality, such that when the individual's expectations or goals are different from the actual environment in which he or she must live and it is difficult to change the situation, aspiration strain would be experienced. Moreover, the larger the difference, the greater the strain experienced. The third source of strain is relative deprivation. Deprivation strain was a kind of psychological strain caused by relative poverty or deprivation. This poverty refers not only to economic poverty but also to commonly pursued goals, such as status and opportunities. It occurs when an individual realizes that others with similar or comparable backgrounds have much better lives. The fourth source of strain is a lack of coping skills. Someone who lacks sufficient coping skills when facing a life crisis might undergo coping strain. These situations include unemployment, loss of love, and long-term bullying by classmates. Psychological strains was previously used to predict suicide risk, and many studies have demonstrated that it was significantly associated with suicide (Sun et al., 2015; Suominen et al., 2004). The present study aims to explore the association between psychological strains and suicidal behaviors. Several studies have tested the strain theory of suicide in various samples in the past. The association between psychological strains and suicide has been found in the United States (Zhang and Lester, 2008). This relationship has also been identified among celebrities (Zhang et al., 2013b). The suicide strain theory can also explain the unique pattern of suicide among young women in rural China (Zhang et al., 2011). Many studies have shown a significant positive correlation between strain and suicide-related behaviors (Liu et al., 2019; Zhao and Zhang, 2018). In 2017, a survey based on 539 college students (298 Chinese and 241 American) found that psychological strains predicted suicidal ideation well (Zhang et al., 2017). Previous studies have indicated that psychological strain can predict the suicidal ideation of Chinese workers and that coping strain was found to be the most powerful predictor among the four psychological strains (Zhang et al., 2018). This unique association has also been found in Chinese patients with stomach cancer, and coping strain may be the most important component, whereas aspiration strain and deprivation strain were not significant in stomach cancer patients (Sun and Zhang, 2016). Research on the suicidal behaviors of college students showed that a large number of factors were closely related to suicidal behaviors. These factors include demographic characteristics (such as gender, age, region) and psychopathology (such as depression, anxiety, and despair) (Mackenzie et al., 2011; Park et al., 2014; Schwenk et al., 2010). In China, the suicide rate of rural areas was three times higher than that of urban areas, and consuming insecticide was the most common method of suicide (Phillips et al., 2002). Psychopathology is the most important predictor of suicide. Most studies indicate the approximately 90% of who completed suicide had a prior identifiable mental illness (Arsenault-Lapierre et al., 2004; Hoertel et al., 2015). The family environment (including economic status and family structures), negative life events (such as academic performance), and physical status (such as physical illness) were also important factors affecting suicidal behaviors
2. Methods 2.1. Participants Data for study were collected in Jilin Province, which is located in Northeast China. Jilin Province is an old industrial base in China and is famous for the automotive industry. Three large public universities, located in the cities of Changchun and Jilin, were selected for the study. The three universities were procured from the universities directly under the Ministry of Education, provincial key universities and provincial general universities. The respondents selected were 16- to 28year-old college students. There were no exclusion criteria. A stratified clustered random sampling method was used to sample students from three or four classes in each year. The study was approved by the Institutional Review Board and the Ethics Committee in each of the universities. 2.2. Sample According to previous reports, the prevalence of suicidal behavior was 24%. Given this prevalence of suicidal behavior, a confidence level of 95% and an allowable error of 0.05, the calculated sample size was 1824 individuals. Considering the nonresponse rate, we increased the total sample by an additional 10% of the calculated sample. The final target sample size was 2006 individuals. A total of 2048 questionnaires were distributed, and our response rate was 99.0%. 2.3. Data collection Informed consent was obtained from participants before they began to complete the questionnaire survey during class breaks. The anonymity and confidentiality of the participants’ collected information were secured and promised. 2.4. Measurements 2.4.1. Sociodemographic information The questionnaire contained variables such as age, gender, ethnicity, residence and self-report of single items on health status, psychological status, academic status, and economic status. The self-identification status was collected in a way such that students report on how they view themselves compared to other students. Health status, psychological status, academic status and economic status each contain three options: 1= poor; 2= moderate; 3=good. Participants choose among these options according to their own status, with no professional scales. 2.4.2. Psychological strain scales (PSS) The Psychological Strain Scales (PSS), which showed good validity and reliability both in Chinese and American college samples, were first developed in a Chinese sample to measure the level of strain (Zhang et al., 2014; Zhang and Lyu, 2014). The PSS consist of the four dimensions of psychological strains, namely, value strain, aspiration strain, deprivation strain, and coping strain; each of these dimensions contains 10 items. For example, “I am often confused about what life means to me” corresponds to value strain; “I wish I had a better job now, but I cannot realize it according to some reasons” corresponds to aspiration strain; “Compared to others in my neighborhood (village), I am a poor person” corresponds to deprivation strain; and “Face is so 196
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important to me that I will do everything to protect my public image, even suicide” corresponds to coping strain. Response options for each item were as follows: 1 = never/not me at all; 2 = rarely/not me; 3 = maybe/not sure; 4 = often/like me; 5 = yes, strongly agree/exactly like me. The total score for each of the four strains was obtained by summing the total score of each dimension (10 items). The higher the total score of the PSS was, the greater the level of psychological strains the participants have.
Table 1 Demographic characteristics and suicide risk of college students (N = 1912). Variables
N
Cr (%)
Suicide Risk n Pr (%)
χ2
P*
711 1201
37.2 62.8
94 192
13.2 16.0
2.686
0.101
1009 903
52.8 47.2
120 166
11.9 18.4
15.780
<0.001
1701 211
89.0 11.0
256 30
15.0 14.2
0.102
0.749
1038 874
54.3 45.7
171 115
16.5 13.2
4.102
0.043
1023 889
53.5 46.5
125 161
12.2 56.3
12.978
<0.001
795 535 361 221
41.6 28.0 18.9 11.5
129 74 52 31
16.2 13.8 14.4 14.0
1.776
0.620
1102 810
57.6 42.4
176 110
16.0 13.6
2.098
0.148
121 572 1219
6.3 29.9 63.8
30 116 140
24.8 20.3 11.5
33.496
<0.001
114 382 1416
6.0 20.0 74.0
45 91 150
39.5 23.8 10.6
98.663
<0.001
166 1330 416
8.7 69.6 21.7
45 185 56
27.1 13.9 13.5
21.147
<0.001
380 1256 276
19.9 65.7 14.4
67 186 33
17.6 14.8 12.0
4.112
0.128
Age ≤20 years old >20 years old Gender Male Female Ethnicity Han Other Residence City Country School category Key general Year Year1 Year2 Year3 Year4 and above Only Child Yes No Health status Poor Moderate Good Psychological status Poor Moderate Good Academic status Poor Moderate Good Economic status Poor Moderate Good
2.4.3. Suicidal behaviors questionnaire-revised (SBQ-R) The Suicidal Behaviors Questionnaire-Revised was a psychological self-report questionnaire assessing four components of suicidality and was designed to identify suicide-related thoughts and behaviors. Each of the four items addresses a specific risk factor: lifetime ideation/attempt (item 1), frequency of suicidal ideation over the past 12 months (item 2), disclosure of ideation to someone else (item 3), and likelihood of future suicide attempt (item 4). The aggregate score for the SBQ-R, ranging from 3 to 18, was obtained by summing the scores of all four items, with higher scores reflecting a higher risk of suicidality. The cutoff score for determining significant levels of suicide risk was 7 for undergraduate students (Osman et al., 2001).
2.5. Statistical analysis All analyses were conducted using SPSS Statistical Software Package (version 24.0). χ2 tests were used to compare the demographic characteristics. Logistic regression analysis was employed to explore the relationship between suicidal behaviors and psychological strains. Multivariate logistic regression was adjusted for age, gender and basic demographic characteristics, which were significant factors. Two-tailed p values < 0.05 were considered statistically significant.
3. Results 3.1. Prevalence of suicidal behaviors
Cr, Constituent ratio; Pr, Prevalence rate. ⁎ P values no more than 0.05 were in bold.
A total of 2048 questionnaires were distributed, 2028 questionnaires were returned, and the number of final valid questionnaires was 1912. The demographic characteristics of the sampled respondents are presented in Table 1. Approximately 286 participants were classified with suicide risk according to the cut-off score. Therefore, the prevalence of suicidal behaviors among respondents was 15.0% (286/ 1912). A total of 2.4% of the current sample reported a previous suicide attempt, and 1.9% reported frequent ideation in the past year. The prevalence of suicidal behaviors among males and females was 11.9% (120/1009) and 18.4% (166/ 903), respectively (see Table 1). The mean SBQ-R score was 4.40 (SD = 2.439), which was far below the cutoff score of 7.
3.3. Reliability of the PSS and SBQ-R The Cronbach's α coefficient of the PSS in our study was 0.958, and for each of the four scales, Cronbach's α was not smaller than 0.800 (Cronbach's α was 0.877 for value strain, 0.909 for aspiration strain, 0.902 for deprivation strain, and 0.903 for coping strain). In the present study, Cronbach's α of the SBQ-R was 0.816. 3.4. Effects of psychological strains on suicide behaviors Table 2 summarizes the results of the regression analysis examining the psychological strain dimensions in relation to suicide risk. Logistic regression was performed to test the effects of psychological strains on individual suicide risk. Multivariate analysis was used to adjust for the age, gender and basic demographic characteristics that were significant factors in Table 1 and was performed to explore the relationship between psychological strains and suicidal behaviors. Table 2 lists the results of the univariate analysis of the four strains and the results of the multivariate analysis. All variables were used with the “enter” method to explore the association between psychological strains and suicidal behaviors. There was a significantly positive correlation between the four dimensions of psychological strain and suicide risk in the univariate analysis. Value strain (OR = 1.075, 95%CI: 1.057–1.094), aspiration strain (OR = 1.082, 95%CI: 1.064–1.101), deprivation strain
3.2. Demographic characteristics of the sample The basic characteristics of the study population are presented in Table 1. A total of 1912 individuals (1009 men and 903 women) aged 16–28 years were included in the study. Han nationality accounted for the majority of the respondents (89.0%). The difference in suicidal behaviors between men and women was found to be statistically significant. The difference in suicidal behaviors between city and country was also found to be statistically significant. In addition, the difference in the distribution of suicidal behaviors among school categories was also significant. Health status, psychological status, and academic status were also found to be significantly different in suicidal behaviors. No significant differences were observed by ethnicity, grade, only-child status and economic status. 197
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Table 2 Logistic regression analysis Psychological Strains in relation to suicide risk. Variables
Value Strain Aspiration Strain Deprivation Strain Coping Strain Total PSS score
Univariate analysis OR (95%CI)
P⁎
Multivariate analysis OR (95%CI)
1.075 1.082 1.073 1.095 1.029
<0.001 <0.001 <0.001 <0.001 <0.001
1.017 1.025 1.004 1.050 –
(1.057–1.094) (1.064–1.101) (1.052–1.093) (1.075–1.116) (1.023–1.034)
(0.991–1.043) (0.996–1.054) (0.976–1.033) (1.023–1.077)
P⁎ 0.198 0.089 0.767 <0.001
Multivariate logistic regression: adjusted for age, gender, the basic demographic characteristics which were significant factors in Table 1. ⁎ P values no more than 0.05 were in bold.
with a predictor of suicidality (Zhang and Lv, 2014). Strains may cause negative emotions and/or mental disorders. When the strains from conflicting pressures are extremely unbearable, individuals may seek solution to release the strains, but their coping methods may be inappropriate and destructive (Zhang et al., 2011). The effect of psychological strains on suicidal behaviors was also a very essential issue. It can be used to identify problems related to suicide in their early stages. At present, there are relatively few studies on this issue. Our research shows that psychological strains can significantly predict suicidal behaviors, and those who experience higher psychological strains are more likely to undergo suicidal behaviors. It is essential to take protective measures to reduce suicide and suicide-related problems. The results showed that the four stains were correlated with suicidal behaviors and were a risk factor for suicidal behaviors in the univariate analysis, and coping strain was an essential factor in the predictions of suicidal behavior. The current research indicated that coping strain was a risk factor for the suicidal behaviors of Chinese college students. Almost everyone has experienced a crisis, and people who do not know how to address these negative life events may experience strain (Zhang et al., 2013a). Coping strain mainly exists in such areas as job loss, status loss, loss of face, money loss, marriage disruption, and interpersonal problems. (Kim et al., 2009). The main sources of strain among college students were interpersonal relationships, lack of resources, academic achievement, expectations, diversity, environment and transformation (Hurst et al., 2013). Kwok et al. found that positive coping skills can effectively prevent suicidal ideation, and Gould et al. found that passive coping skills were positively correlated with suicidal ideation among young adults (Gould et al., 2004; Kwok and Shek, 2009). Aspiration strain occurs when an individual's goal expectation is too high and the state of reality does not allow him or her to fulfill his or her desire. For example, the difficulties of children born into families with different social and economic statuses in achieving success differed, which may be unfair for them. These negative emotions may subsequently increase the risk of suicide. Aspiration strain exists in situations of selecting marriage or love partner, choosing education or job, and social achievement (Zhang and Zhao, 2013). Therefore, helping students to be aware and establish healthy values and life perspectives may be an effective way to reduce the risk of suicide. Value strain and deprivation strain are associated with suicidal behaviors in Chinese college students in univariate analysis but are not significant in the multivariate analysis. A person who think that two conflicting values are equally important in his or her everyday life will experience great pressure. However, if one value is more important than the other, the person may have less or little value strain (Zhang and Zhao, 2013). For college students, the sources of value strain include the contradiction between traditional thinking and freedom consciousness, expectations from parents and personal interests, Chinese traditional Confucian thoughts such as male superiority, and other Western social values. In today's developed society, information is widely delivered through televisions, information networks, applications, etc. People compare other people's wealthy lifestyles with theirs, and they may perceive the difference and deprivation strain (Zhang and Tao, 2013). A
(OR = 1.073, 95%CI: 1.052–1.093), coping strain (OR = 1.095, 95%CI: 1.075–1.116), and the total PSS score (OR = 1.029, 95%CI: 1.023–1.034) were also significantly positively correlated with suicide risk. After adjusting for age, gender, and sociodemographic characteristics, among which suicide risk was significant, coping strain (OR = 1.050, 95%CI: 1.023–1.077) was still positively correlated with suicide risk, though corresponding ORs decreased. The association between value strain and deprivation strain and suicide risk was no longer significant. Additionally, the association between aspiration strain and suicide risk was no longer significant. 4. Discussion This study describes the prevalence of suicidal behaviors among college students; it also explores the correlation between psychological strains and suicidal behaviors and whether psychological strains could be a predictor of suicidal behaviors in college students. This study's main findings are that psychological strains was correlated with suicidal behaviors and that coping strain were effective predictors of suicidal behaviors in college students. In this study, we found 2.5% of college students with a previous suicide attempt and 1.9% with frequent ideation in the past year, which was generally similar to but slightly lower than the results of a largescale investigation (Bohon et al., 2016). Large-scale studies of college students have reported that 7.4% of the sample had contemplated suicide and that 1.3% had attempted suicide in a survey of 123,078 students across 153 colleges and universities (Bohon et al., 2016). Previous studies have demonstrated that the prevalence of suicidal ideation among Chinese college students ranged from 9.1% to 26.2% (Meng et al., 2013; Wang et al., 2014; Zhao et al., 2012). Tang et al. (2018) showed that the prevalence of suicidal behaviors among Chinese college students was 7.6% (7.3% for suicidal ideation and 1.3% for suicide attempt), based on a survey of 5972 participants (Tang et al., 2018). Current studies have indicated that females are more likely than men to be classified as a suicide risk, which is similar to previously reported findings (Li et al., 2014; Miotto and Preti, 2008; Yang et al., 2015). This difference may be related to the differences in the social roles, psychological state and physiological structure of young people. Husky et al. (2012) found that living in a metropolitan area can be a risk factor for suicide attempts among adolescents. Moreover, Zarrouq et al. (2015) found that schools located in urban areas can be a sociodemographic risk factor for suicidal behavior (Husky et al., 2012; Zarrouq et al., 2015). Meng et al. (2013) found that there was a positive correlation between rural background and suicidal ideation in China (Meng et al., 2013). This finding may have arisen because of differences in urban-rural culture, lifestyles and environments. General university students were found to have a higher prevalence of suicidal behavior than key university students. We have not found relevant research; thus, this issue may need further investigation. In addition, we also found that self-reported health status, psychological status, and learning status are related to suicidal behavior. The strain theory of suicide can be considered complementary to existing theories explaining suicidal behaviors and mental disorders 198
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college student who comes from a poor family or generally of poor economic condition may experience deprivation strain if he compares himself with schoolmates who come from a richer family. This can also apply to comparison in terms of appearance, academic achievement, etc. Some limitations of the current study and recommendations for future efforts should be considered. First, the study only selected undergraduates from three universities, so their conclusions may not be extended to all college students in China. Future research should increase the sample size and diversity of the campus to explore further associations between psychological strains and suicidal behaviors. Second, the cohort study is more convincing to demonstrate the relationship between psychological strains and suicidal behaviors than a cross-sectional study. Third, these single-item questions on health status, psychological status, academic status, and economic status are obtained through self-reporting by students, without a professional scale. Future research can further prove the association between strain and suicidal behaviors to achieve the purpose of preventing suicidal behaviors in college students. In conclusion, our study of suicidal behaviors in college students suggests that there is an association between psychological strains and suicidal behaviors, and coping strain of individual are critical factors to prevent it. Further studies with large samples from different universities are needed to further understand the relationship.
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Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. CRediT authorship contribution statement Song Yan: Data curation, Formal analysis, Writing - original draft, Writing - review & editing. Bai Wei: Data curation, Formal analysis, Writing - original draft. Wang Mohan: Data curation. Liu Xinyu: Formal analysis. Zhang Lili: Formal analysis. Yu Weiying: Writing review & editing. Li Yuanyuan: Writing - review & editing. Hua Wanqing: Writing - review & editing. Lew Bob: Writing - review & editing. Talib Mansor Abu: Writing - review & editing. Kou Changgui: Data curation. Declaration of Competing Interest All authors declare that they have no conflicts of interest. Acknowledgement The authors wish to acknowledge all the study participants. References Aloba, O., Ojeleye, O., Aloba, T., 2017. The psychometric characteristics of the 4-item Suicidal Behaviors Questionnaire-Revised (SBQ-R) as a screening tool in a non-clinical sample of Nigerian University students. Asian J. Psychiatr. 26, 46–51. https:// doi.org/10.1016/j.ajp.2017.01.017. Arsenault-Lapierre, G., Kim, C., Turecki, G., 2004. Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC Psychiatry 4, 37. Becker, S.P., Holdaway, A.S., Luebbe, A.M., 2018. Suicidal behaviors in college students: frequency, sex differences, and mental health correlates including sluggish cognitive tempo. J. Adolesc. Heal. 63, 181–188. Bohon, L.M., Cotter, K.A., Kravitz, R.L., Cello, P.J., Fernandez y Garcia, E., 2016. The theory of planned behavior as it predicts potential intention to seek mental health services for depression among college students. J. Am Coll. Heal. 64, 593–603. Gould, M.S., Velting, D., Kleinman, M., Lucas, C., Thomas, J.G., Chung, M., 2004. Teenagers’ attitudes about coping strategies and help-seeking behavior for suicidality. J. Am Acad. Child Adolesc. Psychiatry 43, 1124–1133. https://doi.org/10. 1097/01.chi.0000132811.06547.31. Hoertel, N., Franco, S., Wall, M.M., Oquendo, M.A., Kerridge, B.T., Limosin, F., Blanco, C., 2015. Mental disorders and risk of suicide attempt: a national prospective study. Mol. Psychiatry 20, 718–726.
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Psychol. Med. 40, 581–589. https://doi.org/10.1017/s0033291709990808. Zhang, J., Wieczorek, W.F., Conwell, Y., Tu, X.M., 2011. Psychological strains and youth suicide in rural China. Soc. Sci. Med. 72, 2003–2010. https://doi.org/10.1016/j. socscimed.2011.03.048. Zhang, J., Zhao, S., 2013. Effects of value strains on psychopathology of Chinese rural youths. Asian J. Psychiatr. 6, 510–514. https://doi.org/10.1016/j.ajp.2013.06.007. Zhao, J., X, Y., Xiao, R., Zhang, X., Aguilera, D., Zhao, J., 2012. Belief system, meaningfulness, and psychopathology associated with suicidality among Chinese college students: a cross-sectional survey. BMC Public Health 12, 668. Zhao, S., Zhang, J., 2018. The association between depression, suicidal ideation and psychological strains in college students: a cross-national study. Cult. Med. Psychiatry 42, 914–928. https://doi.org/10.1007/s11013-018-9591-x.
Zhang, J., Lv, J., 2014. Psychological strains and depression in Chinese rural populations. Psychol. Heal. Med. 19, 365–373. https://doi.org/10.1080/13548506.2013.808752. Zhang, J., Lyu, J., 2014. Reliability, validity and preliminary hypothesis tests for the English version of the psychological strain scales (PSS). J. Affect. Disord. 164, 69–75. Zhang, J., Tan, J., Lester, D., 2013b. Psychological strains found in the suicides of 72 celebrities. J. Affect. Disord. 149, 230–234. https://doi.org/10.1016/j.jad.2013.01. 031. Zhang, J., Tao, M., 2013. Relative deprivation and psychopathology of Chinese college students. J. Affect. Disord. 150, 903–907. https://doi.org/10.1016/j.jad.2013.05. 013. Zhang, J., Wieczorek, W., Conwell, Y., Tu, X.M., Wu, B.Y., Xiao, S., Jia, C., 2010. Characteristics of young rural Chinese suicides: a psychological autopsy study.
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Research paper
The association between psychological strain and suicidal behaviors among college students: A mental health survey in Jilin Province, Northeast China
T
Song Yana, Bai Weia, Wang Mohana, Liu Xinyua, Zhang Lilia, Yu Weiyinga, Li Yuanyuana, ⁎ Hua Wanqinga, Lew Bobb, Talib Mansor Abuc, Kou Changguia, a
Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, No. 1163 Xinmin Street, Changchun, Jilin 130021, China Department of Social Psychology, Putra University of Malaysia, Malaysia c Department of Human Development and Family Study, Putra University of Malaysia, Malaysia b
A R T I C LE I N FO
A B S T R A C T
Keywords: Psychological strain Suicide Mental health
Background: Suicide is a major global mental health problem among college students. The aim of the current study was to explore the association between the psychological strains of the strain theory of suicide and suicidal behaviors among college students. Methods: Participants comprised 1912 college students (16–28 years old, 47.2% female) from three universities in Jilin Province, China, who completed the self-report assessments of psychological strains (40 items Psychological Strains Scale) and suicidal behaviors (Suicidal Behaviors Questionnaire-Revised). The demographic characteristics included four variables: health status, psychological status, academic status and economic status. Results: Approximately 15.0% (286/1912) of participants were classified as having suicide risk, based on the cut-off scores of the SBQ-R. The prevalence of suicidal behaviors among males and females was 11.9% (120/ 1009) and 18.4% (166/903), respectively. Value strain (OR = 1.075, 95%CI: 1.057–1.094), aspiration strain (OR = 1.082, 95%CI: 1.064–1.101), deprivation strain (OR = 1.073, 95%CI: 1.052–1.093), and coping strain (OR = 1.095, 95%CI: 1.075–1.116) were risk factors for suicidality in college students. Coping strain (OR = 1.050, 95%CI: 1.023–1.077) was still positively associated with suicide risk in multivariate logistic regression. Logistic regression analysis indicated that coping strain had the highest correlation with suicidal behaviors. Limitations: The directionality of the relationships cannot be deduced because this study is cross-sectional. Conclusion: This study confirms a strong association between psychological strains and suicidal behaviors in college students. Some measures can be taken to reduce psychological strains to mitigate suicide risk among college students. More studies investigating coping strain among college students are warranted.
1. Introduction Suicide, the most tragic outcome, is the second-leading cause of death in young adults as well as in college students (MendezBustos et al., 2013). According to the World Health Organization (WHO), the number of people who die of suicide is nearly 1 million worldwide per year, and it is estimated that this figure will reach 1.5 million by 2020 (Aloba et al., 2017). Suicide has become a major public health issue. A review of suicidal ideation among Chinese college students showed that the overall pooled prevalence was 11.1% and ranged from 4.9% to 35.6% (Li et al., 2014). Substantial research has focused on common suicidal thoughts and behaviors (e.g., ideation, plans, and/
⁎
or attempts) in college students to advance appropriate prevention and intervention work (Holdaway et al., 2018; Wilcox et al., 2010). For example, in a survey of approximately 1700 college students, it was reported that 32.2% of them had brief passing thoughts of suicidal ideation and 4.7% had suicidal plans at least once and truly had intentions to die (Becker et al., 2018). Based on these previous studies, this study examined a comprehensive set of measures, including previous ideation or attempts, ideation frequency, communication with someone with suicidal intentions, and future likelihood of suicide attempts, in a sample of 1912 college students. The strain theory of suicide is a sociopsychological theoretical framework on suicidality that was first conceptualized by Zhang J in 2005.
Corresponding author. E-mail address: [email protected] (C. Kou).
https://doi.org/10.1016/j.jad.2019.08.042 Received 27 January 2019; Received in revised form 5 July 2019; Accepted 17 August 2019 Available online 19 August 2019 0165-0327/ © 2019 Published by Elsevier B.V.
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(Zhai et al., 2015). Against this background, the present study had two objectives. First, we described demographic characteristics and the prevalence of suicidal behaviors in a sample of college students. Second, we explored the unique association between psychological strains and suicidal behaviors.
It explained the unique patterns of rural suicide victims in China (Zhang, 2005). The strain theory of suicide assumes that strains caused by psychological stress or frustration in an individual's life usually precede suicidal behaviors (Zhang et al., 2010). A psychological strain consists of at least two opposite pressures or social experiences in a person's daily life, and this experience will generate strain when he or she experiences extremely conflicting thoughts or experiences. Psychological strains encompass four types: value strain, aspiration strain, deprivation strain, and coping strain. Each strain can be derived from specific sources. Psychological strains can be attributed to different sources. The first source is differential value conflicts, in which the individual experiences value strain when he or she recognizes equally important but conflicting values or beliefs competing in his or her daily life. The second source of strain is a discrepancy between aspiration and reality, such that when the individual's expectations or goals are different from the actual environment in which he or she must live and it is difficult to change the situation, aspiration strain would be experienced. Moreover, the larger the difference, the greater the strain experienced. The third source of strain is relative deprivation. Deprivation strain was a kind of psychological strain caused by relative poverty or deprivation. This poverty refers not only to economic poverty but also to commonly pursued goals, such as status and opportunities. It occurs when an individual realizes that others with similar or comparable backgrounds have much better lives. The fourth source of strain is a lack of coping skills. Someone who lacks sufficient coping skills when facing a life crisis might undergo coping strain. These situations include unemployment, loss of love, and long-term bullying by classmates. Psychological strains was previously used to predict suicide risk, and many studies have demonstrated that it was significantly associated with suicide (Sun et al., 2015; Suominen et al., 2004). The present study aims to explore the association between psychological strains and suicidal behaviors. Several studies have tested the strain theory of suicide in various samples in the past. The association between psychological strains and suicide has been found in the United States (Zhang and Lester, 2008). This relationship has also been identified among celebrities (Zhang et al., 2013b). The suicide strain theory can also explain the unique pattern of suicide among young women in rural China (Zhang et al., 2011). Many studies have shown a significant positive correlation between strain and suicide-related behaviors (Liu et al., 2019; Zhao and Zhang, 2018). In 2017, a survey based on 539 college students (298 Chinese and 241 American) found that psychological strains predicted suicidal ideation well (Zhang et al., 2017). Previous studies have indicated that psychological strain can predict the suicidal ideation of Chinese workers and that coping strain was found to be the most powerful predictor among the four psychological strains (Zhang et al., 2018). This unique association has also been found in Chinese patients with stomach cancer, and coping strain may be the most important component, whereas aspiration strain and deprivation strain were not significant in stomach cancer patients (Sun and Zhang, 2016). Research on the suicidal behaviors of college students showed that a large number of factors were closely related to suicidal behaviors. These factors include demographic characteristics (such as gender, age, region) and psychopathology (such as depression, anxiety, and despair) (Mackenzie et al., 2011; Park et al., 2014; Schwenk et al., 2010). In China, the suicide rate of rural areas was three times higher than that of urban areas, and consuming insecticide was the most common method of suicide (Phillips et al., 2002). Psychopathology is the most important predictor of suicide. Most studies indicate the approximately 90% of who completed suicide had a prior identifiable mental illness (Arsenault-Lapierre et al., 2004; Hoertel et al., 2015). The family environment (including economic status and family structures), negative life events (such as academic performance), and physical status (such as physical illness) were also important factors affecting suicidal behaviors
2. Methods 2.1. Participants Data for study were collected in Jilin Province, which is located in Northeast China. Jilin Province is an old industrial base in China and is famous for the automotive industry. Three large public universities, located in the cities of Changchun and Jilin, were selected for the study. The three universities were procured from the universities directly under the Ministry of Education, provincial key universities and provincial general universities. The respondents selected were 16- to 28year-old college students. There were no exclusion criteria. A stratified clustered random sampling method was used to sample students from three or four classes in each year. The study was approved by the Institutional Review Board and the Ethics Committee in each of the universities. 2.2. Sample According to previous reports, the prevalence of suicidal behavior was 24%. Given this prevalence of suicidal behavior, a confidence level of 95% and an allowable error of 0.05, the calculated sample size was 1824 individuals. Considering the nonresponse rate, we increased the total sample by an additional 10% of the calculated sample. The final target sample size was 2006 individuals. A total of 2048 questionnaires were distributed, and our response rate was 99.0%. 2.3. Data collection Informed consent was obtained from participants before they began to complete the questionnaire survey during class breaks. The anonymity and confidentiality of the participants’ collected information were secured and promised. 2.4. Measurements 2.4.1. Sociodemographic information The questionnaire contained variables such as age, gender, ethnicity, residence and self-report of single items on health status, psychological status, academic status, and economic status. The self-identification status was collected in a way such that students report on how they view themselves compared to other students. Health status, psychological status, academic status and economic status each contain three options: 1= poor; 2= moderate; 3=good. Participants choose among these options according to their own status, with no professional scales. 2.4.2. Psychological strain scales (PSS) The Psychological Strain Scales (PSS), which showed good validity and reliability both in Chinese and American college samples, were first developed in a Chinese sample to measure the level of strain (Zhang et al., 2014; Zhang and Lyu, 2014). The PSS consist of the four dimensions of psychological strains, namely, value strain, aspiration strain, deprivation strain, and coping strain; each of these dimensions contains 10 items. For example, “I am often confused about what life means to me” corresponds to value strain; “I wish I had a better job now, but I cannot realize it according to some reasons” corresponds to aspiration strain; “Compared to others in my neighborhood (village), I am a poor person” corresponds to deprivation strain; and “Face is so 196
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important to me that I will do everything to protect my public image, even suicide” corresponds to coping strain. Response options for each item were as follows: 1 = never/not me at all; 2 = rarely/not me; 3 = maybe/not sure; 4 = often/like me; 5 = yes, strongly agree/exactly like me. The total score for each of the four strains was obtained by summing the total score of each dimension (10 items). The higher the total score of the PSS was, the greater the level of psychological strains the participants have.
Table 1 Demographic characteristics and suicide risk of college students (N = 1912). Variables
N
Cr (%)
Suicide Risk n Pr (%)
χ2
P*
711 1201
37.2 62.8
94 192
13.2 16.0
2.686
0.101
1009 903
52.8 47.2
120 166
11.9 18.4
15.780
<0.001
1701 211
89.0 11.0
256 30
15.0 14.2
0.102
0.749
1038 874
54.3 45.7
171 115
16.5 13.2
4.102
0.043
1023 889
53.5 46.5
125 161
12.2 56.3
12.978
<0.001
795 535 361 221
41.6 28.0 18.9 11.5
129 74 52 31
16.2 13.8 14.4 14.0
1.776
0.620
1102 810
57.6 42.4
176 110
16.0 13.6
2.098
0.148
121 572 1219
6.3 29.9 63.8
30 116 140
24.8 20.3 11.5
33.496
<0.001
114 382 1416
6.0 20.0 74.0
45 91 150
39.5 23.8 10.6
98.663
<0.001
166 1330 416
8.7 69.6 21.7
45 185 56
27.1 13.9 13.5
21.147
<0.001
380 1256 276
19.9 65.7 14.4
67 186 33
17.6 14.8 12.0
4.112
0.128
Age ≤20 years old >20 years old Gender Male Female Ethnicity Han Other Residence City Country School category Key general Year Year1 Year2 Year3 Year4 and above Only Child Yes No Health status Poor Moderate Good Psychological status Poor Moderate Good Academic status Poor Moderate Good Economic status Poor Moderate Good
2.4.3. Suicidal behaviors questionnaire-revised (SBQ-R) The Suicidal Behaviors Questionnaire-Revised was a psychological self-report questionnaire assessing four components of suicidality and was designed to identify suicide-related thoughts and behaviors. Each of the four items addresses a specific risk factor: lifetime ideation/attempt (item 1), frequency of suicidal ideation over the past 12 months (item 2), disclosure of ideation to someone else (item 3), and likelihood of future suicide attempt (item 4). The aggregate score for the SBQ-R, ranging from 3 to 18, was obtained by summing the scores of all four items, with higher scores reflecting a higher risk of suicidality. The cutoff score for determining significant levels of suicide risk was 7 for undergraduate students (Osman et al., 2001).
2.5. Statistical analysis All analyses were conducted using SPSS Statistical Software Package (version 24.0). χ2 tests were used to compare the demographic characteristics. Logistic regression analysis was employed to explore the relationship between suicidal behaviors and psychological strains. Multivariate logistic regression was adjusted for age, gender and basic demographic characteristics, which were significant factors. Two-tailed p values < 0.05 were considered statistically significant.
3. Results 3.1. Prevalence of suicidal behaviors
Cr, Constituent ratio; Pr, Prevalence rate. ⁎ P values no more than 0.05 were in bold.
A total of 2048 questionnaires were distributed, 2028 questionnaires were returned, and the number of final valid questionnaires was 1912. The demographic characteristics of the sampled respondents are presented in Table 1. Approximately 286 participants were classified with suicide risk according to the cut-off score. Therefore, the prevalence of suicidal behaviors among respondents was 15.0% (286/ 1912). A total of 2.4% of the current sample reported a previous suicide attempt, and 1.9% reported frequent ideation in the past year. The prevalence of suicidal behaviors among males and females was 11.9% (120/1009) and 18.4% (166/ 903), respectively (see Table 1). The mean SBQ-R score was 4.40 (SD = 2.439), which was far below the cutoff score of 7.
3.3. Reliability of the PSS and SBQ-R The Cronbach's α coefficient of the PSS in our study was 0.958, and for each of the four scales, Cronbach's α was not smaller than 0.800 (Cronbach's α was 0.877 for value strain, 0.909 for aspiration strain, 0.902 for deprivation strain, and 0.903 for coping strain). In the present study, Cronbach's α of the SBQ-R was 0.816. 3.4. Effects of psychological strains on suicide behaviors Table 2 summarizes the results of the regression analysis examining the psychological strain dimensions in relation to suicide risk. Logistic regression was performed to test the effects of psychological strains on individual suicide risk. Multivariate analysis was used to adjust for the age, gender and basic demographic characteristics that were significant factors in Table 1 and was performed to explore the relationship between psychological strains and suicidal behaviors. Table 2 lists the results of the univariate analysis of the four strains and the results of the multivariate analysis. All variables were used with the “enter” method to explore the association between psychological strains and suicidal behaviors. There was a significantly positive correlation between the four dimensions of psychological strain and suicide risk in the univariate analysis. Value strain (OR = 1.075, 95%CI: 1.057–1.094), aspiration strain (OR = 1.082, 95%CI: 1.064–1.101), deprivation strain
3.2. Demographic characteristics of the sample The basic characteristics of the study population are presented in Table 1. A total of 1912 individuals (1009 men and 903 women) aged 16–28 years were included in the study. Han nationality accounted for the majority of the respondents (89.0%). The difference in suicidal behaviors between men and women was found to be statistically significant. The difference in suicidal behaviors between city and country was also found to be statistically significant. In addition, the difference in the distribution of suicidal behaviors among school categories was also significant. Health status, psychological status, and academic status were also found to be significantly different in suicidal behaviors. No significant differences were observed by ethnicity, grade, only-child status and economic status. 197
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Table 2 Logistic regression analysis Psychological Strains in relation to suicide risk. Variables
Value Strain Aspiration Strain Deprivation Strain Coping Strain Total PSS score
Univariate analysis OR (95%CI)
P⁎
Multivariate analysis OR (95%CI)
1.075 1.082 1.073 1.095 1.029
<0.001 <0.001 <0.001 <0.001 <0.001
1.017 1.025 1.004 1.050 –
(1.057–1.094) (1.064–1.101) (1.052–1.093) (1.075–1.116) (1.023–1.034)
(0.991–1.043) (0.996–1.054) (0.976–1.033) (1.023–1.077)
P⁎ 0.198 0.089 0.767 <0.001
Multivariate logistic regression: adjusted for age, gender, the basic demographic characteristics which were significant factors in Table 1. ⁎ P values no more than 0.05 were in bold.
with a predictor of suicidality (Zhang and Lv, 2014). Strains may cause negative emotions and/or mental disorders. When the strains from conflicting pressures are extremely unbearable, individuals may seek solution to release the strains, but their coping methods may be inappropriate and destructive (Zhang et al., 2011). The effect of psychological strains on suicidal behaviors was also a very essential issue. It can be used to identify problems related to suicide in their early stages. At present, there are relatively few studies on this issue. Our research shows that psychological strains can significantly predict suicidal behaviors, and those who experience higher psychological strains are more likely to undergo suicidal behaviors. It is essential to take protective measures to reduce suicide and suicide-related problems. The results showed that the four stains were correlated with suicidal behaviors and were a risk factor for suicidal behaviors in the univariate analysis, and coping strain was an essential factor in the predictions of suicidal behavior. The current research indicated that coping strain was a risk factor for the suicidal behaviors of Chinese college students. Almost everyone has experienced a crisis, and people who do not know how to address these negative life events may experience strain (Zhang et al., 2013a). Coping strain mainly exists in such areas as job loss, status loss, loss of face, money loss, marriage disruption, and interpersonal problems. (Kim et al., 2009). The main sources of strain among college students were interpersonal relationships, lack of resources, academic achievement, expectations, diversity, environment and transformation (Hurst et al., 2013). Kwok et al. found that positive coping skills can effectively prevent suicidal ideation, and Gould et al. found that passive coping skills were positively correlated with suicidal ideation among young adults (Gould et al., 2004; Kwok and Shek, 2009). Aspiration strain occurs when an individual's goal expectation is too high and the state of reality does not allow him or her to fulfill his or her desire. For example, the difficulties of children born into families with different social and economic statuses in achieving success differed, which may be unfair for them. These negative emotions may subsequently increase the risk of suicide. Aspiration strain exists in situations of selecting marriage or love partner, choosing education or job, and social achievement (Zhang and Zhao, 2013). Therefore, helping students to be aware and establish healthy values and life perspectives may be an effective way to reduce the risk of suicide. Value strain and deprivation strain are associated with suicidal behaviors in Chinese college students in univariate analysis but are not significant in the multivariate analysis. A person who think that two conflicting values are equally important in his or her everyday life will experience great pressure. However, if one value is more important than the other, the person may have less or little value strain (Zhang and Zhao, 2013). For college students, the sources of value strain include the contradiction between traditional thinking and freedom consciousness, expectations from parents and personal interests, Chinese traditional Confucian thoughts such as male superiority, and other Western social values. In today's developed society, information is widely delivered through televisions, information networks, applications, etc. People compare other people's wealthy lifestyles with theirs, and they may perceive the difference and deprivation strain (Zhang and Tao, 2013). A
(OR = 1.073, 95%CI: 1.052–1.093), coping strain (OR = 1.095, 95%CI: 1.075–1.116), and the total PSS score (OR = 1.029, 95%CI: 1.023–1.034) were also significantly positively correlated with suicide risk. After adjusting for age, gender, and sociodemographic characteristics, among which suicide risk was significant, coping strain (OR = 1.050, 95%CI: 1.023–1.077) was still positively correlated with suicide risk, though corresponding ORs decreased. The association between value strain and deprivation strain and suicide risk was no longer significant. Additionally, the association between aspiration strain and suicide risk was no longer significant. 4. Discussion This study describes the prevalence of suicidal behaviors among college students; it also explores the correlation between psychological strains and suicidal behaviors and whether psychological strains could be a predictor of suicidal behaviors in college students. This study's main findings are that psychological strains was correlated with suicidal behaviors and that coping strain were effective predictors of suicidal behaviors in college students. In this study, we found 2.5% of college students with a previous suicide attempt and 1.9% with frequent ideation in the past year, which was generally similar to but slightly lower than the results of a largescale investigation (Bohon et al., 2016). Large-scale studies of college students have reported that 7.4% of the sample had contemplated suicide and that 1.3% had attempted suicide in a survey of 123,078 students across 153 colleges and universities (Bohon et al., 2016). Previous studies have demonstrated that the prevalence of suicidal ideation among Chinese college students ranged from 9.1% to 26.2% (Meng et al., 2013; Wang et al., 2014; Zhao et al., 2012). Tang et al. (2018) showed that the prevalence of suicidal behaviors among Chinese college students was 7.6% (7.3% for suicidal ideation and 1.3% for suicide attempt), based on a survey of 5972 participants (Tang et al., 2018). Current studies have indicated that females are more likely than men to be classified as a suicide risk, which is similar to previously reported findings (Li et al., 2014; Miotto and Preti, 2008; Yang et al., 2015). This difference may be related to the differences in the social roles, psychological state and physiological structure of young people. Husky et al. (2012) found that living in a metropolitan area can be a risk factor for suicide attempts among adolescents. Moreover, Zarrouq et al. (2015) found that schools located in urban areas can be a sociodemographic risk factor for suicidal behavior (Husky et al., 2012; Zarrouq et al., 2015). Meng et al. (2013) found that there was a positive correlation between rural background and suicidal ideation in China (Meng et al., 2013). This finding may have arisen because of differences in urban-rural culture, lifestyles and environments. General university students were found to have a higher prevalence of suicidal behavior than key university students. We have not found relevant research; thus, this issue may need further investigation. In addition, we also found that self-reported health status, psychological status, and learning status are related to suicidal behavior. The strain theory of suicide can be considered complementary to existing theories explaining suicidal behaviors and mental disorders 198
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college student who comes from a poor family or generally of poor economic condition may experience deprivation strain if he compares himself with schoolmates who come from a richer family. This can also apply to comparison in terms of appearance, academic achievement, etc. Some limitations of the current study and recommendations for future efforts should be considered. First, the study only selected undergraduates from three universities, so their conclusions may not be extended to all college students in China. Future research should increase the sample size and diversity of the campus to explore further associations between psychological strains and suicidal behaviors. Second, the cohort study is more convincing to demonstrate the relationship between psychological strains and suicidal behaviors than a cross-sectional study. Third, these single-item questions on health status, psychological status, academic status, and economic status are obtained through self-reporting by students, without a professional scale. Future research can further prove the association between strain and suicidal behaviors to achieve the purpose of preventing suicidal behaviors in college students. In conclusion, our study of suicidal behaviors in college students suggests that there is an association between psychological strains and suicidal behaviors, and coping strain of individual are critical factors to prevent it. Further studies with large samples from different universities are needed to further understand the relationship.
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Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. CRediT authorship contribution statement Song Yan: Data curation, Formal analysis, Writing - original draft, Writing - review & editing. Bai Wei: Data curation, Formal analysis, Writing - original draft. Wang Mohan: Data curation. Liu Xinyu: Formal analysis. Zhang Lili: Formal analysis. Yu Weiying: Writing review & editing. Li Yuanyuan: Writing - review & editing. Hua Wanqing: Writing - review & editing. Lew Bob: Writing - review & editing. Talib Mansor Abu: Writing - review & editing. Kou Changgui: Data curation. Declaration of Competing Interest All authors declare that they have no conflicts of interest. Acknowledgement The authors wish to acknowledge all the study participants. References Aloba, O., Ojeleye, O., Aloba, T., 2017. The psychometric characteristics of the 4-item Suicidal Behaviors Questionnaire-Revised (SBQ-R) as a screening tool in a non-clinical sample of Nigerian University students. Asian J. Psychiatr. 26, 46–51. https:// doi.org/10.1016/j.ajp.2017.01.017. Arsenault-Lapierre, G., Kim, C., Turecki, G., 2004. Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC Psychiatry 4, 37. Becker, S.P., Holdaway, A.S., Luebbe, A.M., 2018. Suicidal behaviors in college students: frequency, sex differences, and mental health correlates including sluggish cognitive tempo. J. Adolesc. Heal. 63, 181–188. Bohon, L.M., Cotter, K.A., Kravitz, R.L., Cello, P.J., Fernandez y Garcia, E., 2016. The theory of planned behavior as it predicts potential intention to seek mental health services for depression among college students. J. Am Coll. Heal. 64, 593–603. Gould, M.S., Velting, D., Kleinman, M., Lucas, C., Thomas, J.G., Chung, M., 2004. Teenagers’ attitudes about coping strategies and help-seeking behavior for suicidality. J. Am Acad. Child Adolesc. Psychiatry 43, 1124–1133. https://doi.org/10. 1097/01.chi.0000132811.06547.31. Hoertel, N., Franco, S., Wall, M.M., Oquendo, M.A., Kerridge, B.T., Limosin, F., Blanco, C., 2015. Mental disorders and risk of suicide attempt: a national prospective study. Mol. Psychiatry 20, 718–726.
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