A cohort analysis from Japan shows that more visible symptoms—though considered less clinical by experts—may be indicative of heightened suicidal behavior in teenagers.
Adolescents with persistent symptoms of withdrawal and increasing somatic symptoms are at a nearly doubled risk of suicidal thoughts, according to new data. The findings suggest that increased vigilance for these symptoms—as well as utility of social- and psychological-centric care—may be critical to help decrease adolescent suicides.
A new cohort from investigators in Tokyo helped to establish a comprehensive cluster of longitudinal adolescent psychopathological and behavioral symptom trajectories, and to assess their link to suicidal thoughts at mid-adolescence. Led by Akito Uno, MD, of the department of neuropsychiatry, Graduate School of Medicine, The University of Tokyo, the team wanted to identify the unknown categories and trajectories of symptoms that are associated with higher suicidal behavior risks in adolescents.
“Most adolescent psychopathological and behavioral symptoms are developmentally fluid and nonspecific to any psychiatric diagnosis,” they wrote. “As a result, comorbidity is common and 20% to 50% of adolescents with psychiatric symptoms have more than 1 category of symptoms.”
Up to 1 in 5 adolescents report experiencing suicidal thoughts, an understood predictor of suicide attempts. Because many psychiatric disorders emerge during adolescence, defining the common psychopathology and behavioral symptoms of suicidal adolescents is key.
“Depressive symptoms that persist from adolescence into adulthood, rather than being limited to adolescence, are associated with a higher risk of self-harm with suicidal thoughts in adulthood,” investigators wrote. “It has also been proposed that boys with hyperactivity or inattention symptoms that persist moderately or highly from childhood to adolescence are at a greater risk of suicidal thoughts and attempts during adolescence than those with fewer symptoms trajectory.”
Uno and colleagues used data from the Tokyo Teen Cohort (TTC), a prospective birth cohort analysis of the general population that provides data on the mental and physical development of adolescents. Relevant participants were born between September 2002 – August 2004 across 3 municipalities in Tokyo. The final analysis included 3171 adolescents aged 10 years old at assessment, 3007 at age 12 (94.8% follow-up rate), and 2616 at age 16 (82.5%).
Participants were examined by trainer professionals during 3 at-home visits via self-report questionnaires for themselves and their parents/guardians. They were asked at age 16, “Do you currently think that you should not be alive?” to capture passive suicidal thoughts emerging in early stages of the suicide spectrum.
Participants’ Child Behavior Checklist (CBCL) scores gauged pathophysiological and behavioral symptoms at 3 separate points of the assessment; the metric includes 8 subscales for the following symptoms, graded from a severity score of 0 – 2:
Psychopathological and behavioral symptom trajectories were clustered through a latent class growth analysis on the 8 CBCL subscale scores.
Among the 1920 adolescents from the cohort with data on suicidal thoughts, 158 (8.2%) reported having them. Thought the clustered pattern of trajectories varied across the observed symptoms, investigators found adolescents with persistent high withdrawn symptoms (OR, 1.88; 95% CI , 1.10 – 3.21) and those with increasing somatic symptoms (OR, 1.97; 95% CI, 1.16 – 3.34) had significantly greater risk of suicidal thoughts versus symptoms without such symptoms. Investigators did not observe an interaction between the symptom trajectories and risk of suicidal thoughts, however.
“Persistent high withdrawn symptoms were shown to be associated with an elevated risk of suicidal thoughts in midadolescence, consistent with previous studies,” investigators wrote. “Since the cross-sectional association between withdrawn symptoms and suicidal thoughts was also significant, caution is needed in interpreting the importance of the persistent trajectory itself. Although social withdrawal is complicated by many psychiatric disorders, including anxiety and phobic disorder and major depression, we found an independent association between withdrawn symptoms and suicidal thoughts.”
The team emphasized that clinicians should pay attention to possible signs of withdrawn and somatic symptoms in adolescent patients; because of how social withdrawal and somatic symptoms independently associate with suicidal thoughts, intervention like improved social connections and psychological support may be critical in their care.
“This is valuable for a wide range of people involved in adolescent health, as social withdrawal and common somatic symptoms are often more noticeable than emotional symptoms such as depression,” they concluded. "Although social withdrawal and somatic symptoms may not receive sufficient clinical attention, our findings showed their crucial role in suicide prevention, particularly when they persist or increase in the longitudinal follow-up.”
Uno A, Nagaoka D, Usami S, et al. Suicidal Thoughts and Trajectories of Psychopathological and Behavioral Symptoms in Adolescence. JAMA Netw Open. 2024;7(1):e2353166. doi:10.1001/jamanetworkopen.2023.53166
OrriM, ScarderaS, PerretLC,et al. Mental health problems and risk of suicidal ideation and attempts in adolescents. Pediatrics. 2020;146(1):e20193823. doi:10.1542/peds.2019-3823