Adolescent suicide is a serious problem worldwide. In Korea, suicide has been the number one cause of adolescent death since 2007 (Statistics Korea [KOSTAT], 2019). According to KOSTAT (2019), youth suicide occurred in 7.7 people per 100,000 in 2017, the 11th highest among the Organization for Economic Cooperation and Development countries (Korean Suicide Prevention Center, 2019). In addition, the age of adolescents attempting suicide is gradually becoming younger (Yi et al., 2011), with >5% of middle and high school students experiencing suicidal ideation (Youm et al., 2016). Adolescent suicide is a serious threat to one's personal life, but also to family, friends, neighbors, and community members (Choi & Kwon, 2014). Therefore, various interventions are needed to prevent adolescent suicide.
Attitude toward mental health services is an important factor related to suicide behavior (Ko, 2017). Attitude toward mental health services refers to attitudes and behaviors regarding the seeking of professional help, such as counseling and treatment, in the event of psychological difficulties (Ko et al., 2019). Attitude toward mental health services includes recognition of the need for professional psychological help; tolerance of stigma associated with seeking professional psychological help; interpersonal openness; and confidence in the mental health profession (Fischer & Turner, 1970). According to results of a psychological autopsy study on 56 adults who died by suicide (Sea et al., 2012), 58.9% of individuals tried to seek professional help but did not follow through, 37.5% never tried to seek professional help, and only one individual (1.8%) asked for help.
Suicidal ideation is a predictor of suicide and suicide attempts (Abdollahi et al., 2015; Groleger et al., 2003; Korean Suicide Prevention Center, 2019), and can affect individuals throughout their entire lives (Kim, 2011). Most people who attempt suicide have previously fantasized about death, so suicidal ideation is considered the first step, and a warning sign, of suicide attempt (Horwitz et al., 2015). In one study, individuals with suicidal ideation were 12 times more likely to commit suicide than individuals without suicidal ideation (Reinherz et al., 2006). Therefore, as a preventive approach to adolescent suicide, attention to suicidal ideation and identifying factors related to its occurrence are important. Thus, the relationship between adolescents' attitude toward mental health services and suicidal ideation needs to be studied.
Depressive symptoms are another strong predictor of suicidal ideation (Chang & Kim, 2019; Kandel et al., 1991). Untreated depression is a major cause of suicidal behavior. In South Korea, untreated psychiatric disorders, including depression, were the cause of suicide in 56% of cases (Korean Centers for Disease Control, 2017; Ministry of Health and Welfare, 2018). In South Korea, 25.1% of adolescents have experienced depression during the past 1 year (Korean Suicide Prevention Center, 2019). Depression usually begins during adolescence, which can affect impulse and behavioral problems (Birmaher et al., 2004; Patton & Viner, 2007). Specifically, failure to properly manage negative emotions such as depression and anxiety in adolescence can result in destructive behaviors, and there is a high risk of impulsive thinking or attempting to commit suicide even when faced with minor problems (Park et al., 2018). Moreover, depression can affect suicidal ideation in adolescents, with more severe depression showing greater suicidal ideation (Groleger et al., 2003; Kim, 2011). Therefore, depression is thought to be relevant to adolescents' suicidal ideation and should be treated as an important variable.
Sleep is an essential factor in maintaining daily life and health, and adolescents need at least 8 to 10 hours of sleep due to rapid physical growth and hormonal changes (Choi & Seo, 2017). However, many teenagers do not get enough sleep, which can easily develop into chronic sleep deprivation. Sleep disorders have been shown to be high risk factors for suicide (Bernert et al., 2015), and individuals with persistent insomnia are approximately twice as likely to commit suicide as those who do not have such sleep problems (Suh et al., 2013). In teenagers, feelings of desperation and suicidal ideation increase with every 1 hour of lost sleep time compared to adequate sleep time (Winsler et al., 2015). Therefore, when examining factors that influence suicidal ideation, sleep quality, as well as depression, should be included.
Attitude toward mental health services for depression has been rigorously studied in many countries when exploring facilitators of or barriers to seeking professional help among adolescents experiencing suicidal ideation. Understanding attitude toward mental health services of adolescents who are thinking about or planning to attempt suicide and how this attitude contributes as an influencing factor to suicidal ideation is important. However, research about attitude toward mental health services with psychosocial outcomes in adolescence remains unclear. In particular, research on how attitude toward mental health services influences suicidal ideation is insufficient.
The purpose of the current study was to examine the mediating effects between attitude toward mental health services and suicidal ideation. Specific aims of the study were to examine (a) correlations among variables, including attitude toward mental health services, depression, sleep quality, and suicidal ideation; and (b) the serial-multiple mediation of depression and sleep quality in the relationship between attitude toward mental health services and suicidal ideation. Specifically, three indirect effects were tested: (a) attitude toward mental health services → sleep quality → suicidal ideation; (b) attitude toward mental health services → depression → suicidal ideation; and (c) attitude toward mental health services → sleep quality → depression → suicidal ideation.
Study Design and Sample
The current study examined the serial mediating effect of sleep quality and depression on the relationship between attitude toward mental health services and suicidal ideation among adolescents. A cross-sectional survey design was used with a convenience sampling method. Participants were adolescents in middle and high school in Daejeon City, South Korea. Posters describing the study were placed in classrooms and hallways. Adolescents interested in participating in the study and whose parents provided written consent to the school nurse and counselor were informed of the study purpose. Participants completed a consent form, received the questionnaire, and completed the questionnaire in private in the school nurse's office. Some participants took the questionnaire home to complete; however, these questionnaires were rarely returned.
A total of 151 of 200 surveys were used for analysis; 40 surveys were not returned to the primary investigator (PI; Y.J.) and nine surveys were incomplete. The number of participants required for proper power in the path analysis and structural equation model, with a recommended ratio of observations per measurement parameter of 5:1 or 10:1 (Bentler & Chou, 1987), was 170.
Ethical Considerations and Data Collection
Before recruitment began, the study was approved by Dankook University Institutional Review Board (IRB).
Data were collected from June to August 2019 using a self-administered survey. A teacher in the middle school and the PI gave an invitation and recruitment letter to all students in one middle school and one high school. For those participants who did not fill out the survey in the nurses' office, the consent form and questionnaires were placed in a stamped envelope and sent to adolescents whose parents agreed to their participation in the study. The consent form included a statement about voluntary participation and protection of anonymity and confidentiality. The PI obtained written consent from all participants (i.e., parents and adolescents).
Suicidal Ideation. Suicidal ideation was measured using the 30-item Suicidal Ideation Questionnaire (SIQ; Reynolds, 1988), which was revised and validated by Shin (1992). Item examples include: (1) “I thought about suicide”; (2) “I thought about when to commit suicide”; and (3) “I thought I had no reason to live anymore” (Reynolds, 1988). Items are rated on a 7-point Likert scale (0 = I have never thought this to 6 = I have thought this everyday) and the total score of all items is used (Reynolds, 1988). The higher the total score, the more often suicidal ideation was considered (Reynolds, 1988). Cronbach's alpha for the SIQ was 0.99 in the current study. Kaiser-Meyer-Olkin (KMO) was 0.925 and Bartlett test was significant (χ2 = 6274.896, df = 435, p < 0.001).
Attitude Toward Mental Health Services. Attitude toward seeking professional help for depression was measured using the 10-item Attitudes Toward Seeking Professional Help (ATSPH) questionnaire. Items are scored using a 4-point Likert scale, where 0 = disagree, 1 = partly disagree, 2 = partly agree, and 3 = agree (Whittlesey, 2000). Higher total scores indicate more positive attitudes toward seeking professional help. Items 2, 4, 8, 9, and 10 are reverse scored because they indicate a negative attitude (e.g., Question 10: “Personal and emotional troubles, like many things, tend to work out by themselves.”). At the time of instrument development, Cronbach's alpha was 0.76 (Whittlesey, 2000). The current study's Cronbach's alpha was 0.69. KMO was 0.76 and Bartlett test was significant (χ2 = 345.03, df = 45, p < 0.001).
Depression. The Beck Depression Inventory-II (BDI-II), which comprises 21 items, was used for detecting depression. The Korean version of the BDI-II (K-BDI-II) was purchased from Korea Psychology (2018). Items evaluated depressive symptoms, such as weight loss, change in body image, somatic symptoms, loss of energy, sleep loss, loss of appetite, as well as sadness and loss of interests. The following guidelines have been suggested to interpret BDI-II scores: minimal depression = 0 to 13, mild depression = 14 to 19, moderate depression = 20 to 28, and severe depression = 29 to 63 (Pearson Assessments, 2019). Cronbach's alpha for the BDI-II in the current study was 0.91. KMO was 0.87 and Bartlett test was significant (χ2 = 1209.002, df = 231, p < 0.001).
Sleep Quality. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI), developed by Buysse et al. (1988) and translated by Sohn et al. (2012) into the Korean version (PSQI-K). The PSQI-K measures subjective sleep over the past 1 month and includes 19 questions in seven areas of dysfunction—subjective sleep quality, sleep latencies, sleep duration, habitual sleep effects, sleep disturbances, use of sleeping medications, and daytime sleep. Higher total score of the seven components indicates poorer sleep quality (Buysse, 1988). At the time of instrument development, reliability of the tool was 0.83 (Buysse, 1988), and reliability of the Korean version was 0.84 (Sohn et al., 2012). The current study's Cronbach's alpha was 0.7. KMO was 0.78 and Bartlett test was significant (χ2 = 616.5, df = 21, p < 0.001).
Demographic Questionnaire. Adolescents' age, gender, and body mass index (BMI) were obtained.
Collected data were analyzed using SPSS version 25.0 and SPSS Process Macro 2.15 Program (Preacher & Hayes, 2008). General characteristics of participants were analyzed using descriptive statistics. Correlational analysis applying Pearson's correlation coefficient was conducted to examine correlations among suicidal ideation, depression, sleep quality, and attitude toward mental health services. To test the multiple-mediation hypotheses, a multiple-mediation analysis was performed to determine whether significant relationships between attitude toward mental health services and suicidal ideation were mediated by sleep quality and depression based on the Sobel test (Preacher & Hayes, 2008). As a result of checking the variables affecting suicidal ideation among general characteristics, age, gender, and BMI were included as covariates. If zero is not included in the 95% confidence interval (CI), a significant indirect effect exists (alpha = 0.05). Bootstrapping for testing of the multiple-mediation model was conducted. An indirect effect was considered to be significant if the 95% CI from 5,000 bootstrap samples did not include zero.
Demographic characteristics are shown in Table 1. One hundred fiftyone adolescents (male, n = 87; female, n = 64) participated in the study. Mean age of participants was 15 years (SD = 1.24 years). Mean BMI was 22.82 kg/m2 (SD = 4.09) for boys and 19.92 kg/m2 (SD = 2.49) for girls.
Participant Characteristics (N = 151)
Correlational Analysis Among Variables
Means, standard deviations, and correlations of all variables are shown in Table 2. Suicidal ideation was positively associated with depression (r = 0.706, p < 0.001) and sleep quality (r = 0.173, p = 0.034), and negatively associated with age (r = −0.19, p = 0.02). Attitude toward mental health services was positively correlated with age (r = 0.378, p < 0.001) and negatively correlated with gender (r = −0.376, p < 0.001). Depression was positively correlated with sleep quality (r = 0.293, p < 0.001) and BMI (r = 0.176, p = 0.03). Sleep quality was positively correlated with age (r = 0.285, p < 0.001) and BMI (r = 0.233, p = 0.004), but negatively correlated with gender (r = −0.306, p < 0.001).
Correlations Among Variables
Mediating Effects of Sleep Quality and Depression on the Relationship Between Attitude Toward Mental Health Services and Suicidal Ideation
The results for mediating effect of the multiple mediation model are presented in Table 3 and Figure 1. Age, gender, and BMI were related to suicidal ideation, depression, sleep quality, and attitude toward mental health services; therefore, these variables were controlled to examine the mediating effect of sleep quality and depression on attitude toward mental health services and suicidal ideation.
Serial Mediation Effect of Depression and Sleep Quality in Attitude Toward Mental Health Services and Suicidal Ideation
Mediating effect of sleep quality and depression between attitude toward mental health services and suicidal ideation.
Note. BMI = body mass index.
When sleep quality and depression were controlled, the direct effect from attitude toward mental health services to suicidal ideation was significant (β = 0.26, p = 0.039) and the direct effect from attitude toward mental health services to depression was significant (β = −0.30, p = 0.017); however, the direct effect to sleep quality was not significant. In addition, the direct effect from depression to suicidal ideation was significant (β = 2.80, p < 0.001), but that from sleep quality to suicidal ideation was not significant. A significant mediating effect of depression on the relationship of attitude toward mental health services to suicidal ideation was shown (indirect effect = −0.828; bootstrapping 95% CI [−1.588, −0.063]) (see Path 2 in Table 2). Significant total effect of indirect effect was also shown. However, there was no significant mediating effect of sleep quality between attitude toward mental health services and suicidal ideation.
The current study identified the mediating effect of depression in the relationship between attitude toward mental health services and suicidal ideation and the direct effect of depression and the correlation among depression, sleep quality, attitude toward mental health services, and suicidal ideation in adolescents.
The most interesting finding was the significant mediating effect of depression on the relationship of attitude toward mental health services to suicidal ideation. This result is different from a previously reported negative correlation between increasing attitude toward mental health services and suicide rates (Reynders et al., 2014), and it suggests that depression may mediate suicidal ideation even in adolescents with positive attitudes toward mental health services. Even if adolescents showed a positive attitude about depression and its treatment, depression had a mediating effect, which eventually affected suicidal ideation. These results are in line with prior studies that have shown that people with depressive disorders are at least 40 times more likely to commit suicide than individuals without depressive disorders, and negative perceptions of psychiatric treatment were related to treatment of depression (Lee, 2015). Therefore, these findings suggest that accurate assessment and intervention of depression is a priority for overall prevention of adolescent suicide.
Although early detection and treatment of adolescent depression are vital, depression in adolescence is widely underdiagnosed and undertreated, as adolescents often avoid reporting symptoms of depression and have poor use of mental health services (Dardas et al., 2019). Individuals with suicidal ideation who had never been diagnosed with depression by a health care provider were less likely to seek help than individuals who had been diagnosed with depression (Ko, 2017). These findings imply the need for schools and community systems to detect adolescents at risk of having suicidal ideation and provide them with professional mental health services. In other words, a multidisciplinary approach, including community mental health centers, schools, workplaces, and medical systems, is needed to detect and treat depression early (Jeon, 2011). Screening and referral to services to promote students' mental health is within the scope of school nursing practice (Puskar & Bernardo, 2007). Therefore, adolescents who may be depressed should be identified by a teacher, school nurse, or counselor and referred to mental health services. Reliable and valid screening tools for depression should be administered regularly to all students and high-risk persons should be examined by professional health providers under parental permission. School systems should establish a relationship between schools and health care networks to educate parents on the importance of seeking professional help for their children.
Second, in terms of mediation effect of depression and sleep quality, the direct effect of attitude toward mental health services and depression to suicidal ideation was significant, which was consistent with previous findings. However, the direct effect from sleep quality to suicidal ideation was not significant. This result was not consistent with previous studies on the relationship among depression, sleep quality, and suicide attempts. Previous studies showed that there were significant quantitative correlations among sleep quality, depression, and suicide accidents. For example, adolescents with insufficient sleep time showed more depressive symptoms than those with sufficient sleep time (Gangwisch et al., 2010), and adolescents who did not meet the recommended sleep time for their age were found to think about suicide (Kim et al., 2019). However, the current study showed no impact of sleep quality on suicidal ideation. Depression may be a stronger predictor of suicidal ideation than sleep quality; therefore, the influence of sleep quality on the relationship between attitude toward mental health services and suicidal ideation might be decreased. Previous studies showed strong correlations between sleep quality and suicidal ideation, but there was no causal relationship between sleep quality and depression or suicidal ideation in the current study. Therefore, the impact of sleep quality may need to be examined as a moderating effect or independent effect from depression on the relationship between attitude toward mental health services and suicidal ideation. In addition, other variables that influence suicidal ideation in adolescents should be identified and examined.
Results of the current correlational analysis among depression, sleep quality, attitude toward mental health services, and suicidal ideation showed that suicidal ideation was positively associated with depression and sleep quality, and negatively associated with age. The positive association with depression and sleep quality is similar to findings of previous studies that showed higher suicide rates in adolescents with higher depressive scores (Eaton et al., 2010; Lee & Lee, 2014). Attention to and appropriate measures for adolescents with depression are needed to reduce and prevent suicidal ideation and suicide. As adolescence is a time of emotional instability and stress, and because middle school students, in particular, are experiencing rapid changes in puberty compared to high school students (Park, 2015), it is necessary to pay additional attention to young adolescents with suicidal ideation and/or severe depressive symptoms.
There were a few limitations in the current study. Results cannot be generalized as only students enrolled in two schools participated, and adolescents not attending school were excluded. In addition, to understand multivariate complex suicides, it is necessary to have a deeper understanding of young people who have suicidal ideation. Therefore, qualitative research is needed on adolescents who have experienced suicidal ideation. Although these limitations exist, the current study shows implications for research and interventions regarding adolescent suicidal ideation. Schools should conduct regular screening tests with reliable and validated tools to detect problems, including depression, to prevent suicide. In addition, mental health care systems should be established for early treatment of students who are found to have problems. Parents should also be educated on the importance of seeking professional help for depression.
Depression was found to have a significant mediating effect on the relationship between attitude toward mental health services and suicidal ideation. Regular assessments for depression and subsequent intervention are priorities for the prevention of adolescent suicide.
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Participant Characteristics (N = 151)
|Age (years) (mean, SD, range)||14.99 (1.24) (12 to 16)|
|Gender (n, %)|
| Male||87 (58)|
| Female||64 (42)|
|BMI (kg/m2) (mean, SD, range)|
| Male (n = 87)||22.82 (4.09) (17.07 to 37.55)|
| Female (n = 64)||19.92 (2.49) (16.22 to 30.29)|
Correlations Among Variables
|Variable||Suicidal Ideation||Attitude||Depression||Sleep Quality||Age||BMI|
|Mean (SD)a||23.09 (33.02)||23.05 (6.07)||10.25 (8.49)||7.87 (3.14)||14.99 (1.24)||21.61 (3.78)|
Serial Mediation Effect of Depression and Sleep Quality in Attitude Toward Mental Health Services and Suicidal Ideation
|Indirect (total)||−0.809*||0.399||[−1.580, −0.006]|
|Indirect (1)||0.001||0.047||[−0.095, 0.107]|
|X → M1 → Y|
|Indirect (2)||−0.829*||0.386||[−1.588, −0.063]|
|X → M2 → Y|
|Indirect (3)||0.018||0.149||[−0.320, 0.304]|
|X → M1 → M2 → Y|