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Adolescence, Fall 1993 v28 n111 p649(11) Suicidal thoughts among adolescents: an intercultural approach. Marie Choquet; Viviane Kovess; Nathalie Poutignat.
Author's Abstract: COPYRIGHT Libra Publishers Inc. 1993
Two epidemiological surveys of suicidal ideation were conducted among adolescents, aged 15-18, in France and the Canadian province of Quebec. The results suggest that, in both countries, suicidal ideation was linked to drug use (especially tobacco, illicit drugs, and psychotropic medicine), nonspecific somatic complaints (especially tiredness, sleep difficulties, depression, and feeling tense), a lack of self-esteem (pessimism, instability, boredom), and dissatisfaction with family relationships. There was no relationship between suicidal ideation and sports activities in either country. The implications for prevention are discussed.
Full Text: COPYRIGHT Libra Publishers Inc. 1993
Most studies concerning the "suicide phenomenon" of young people aged 15-19 have analyzed mortality and to a lesser extent morbidity. In France, the suicide rate in 1987 was 14.7 for boys and 4.7 for girls (per 100,000). Concerning attempted suicide, Davidson and Philippe (1986) estimated the rate to be 212 for boys and 456 for girls (per 100,000). In Quebec, the suicide rate is clearly higher for boys, having reached 24.1 in 1981, but similar for girls (5.0) (Kovess & Choquet, 1989). As for attempted suicide, a study conducted in Ontario estimated the rate at 500 for boys and 1,000 for girls (Jarvis et al., 1976). While these studies have measured the prevalence of suicidal behavior and noted the associated risk factors, they have not elucidated the emergence of suicidal ideation or its ensuing chronicity.
Suicidal ideation has been infrequently studied for two main reasons. First, it is not as easy to measure objectively as is suicidal behavior, and information is therefore considered to be less reliable. Ideation may be transient, questions may not be pertinent, and answers are liable to be biased (Jeanneret, 1989). This view is corroborated by the disparity in survey results. Concerning adults, rates range from 9% (Paykel et al., 1974) to 14% (Sorenson & Goldning, 1988). For adolescents, they range from 8% (Wright, 1985) to 62% (Friedman et al., 1987). Further, there is the problem of the wording of the questionnaire (suicidal ideation, precise suicidal plans), as well as that of the proposed answers (binary, multiple choice), and the time span taken into account (lifetime, one year, one week).
Second, the study of suicidal ideation requires large populations, which are generally difficult to obtain (cohorts, cost), particularly concerning such a delicate matter. Those in charge of planning these surveys are often reluctant to carry them out because they fear their inductive capacity, and those who actually conduct the survey may find it difficult to approach the subject. To these considerations may be added the problem of ensuring confidentiality. A related ethical issue is that if a suicidal individual is identified, he or she should be referred for appropriate counseling.
Although difficult, it is necessary to understand the factors that may lead to self-destructive acting out in order to plan primary prevention measures. The present comparative study was undertaken to investigate suicidal ideation in French and Canadian (Quebec) adolescents.
METHOD
Surveys
The two surveys were set up concurrently but independently of one another. Therefore, the results came from secondary analyses. In addition, variations in the wording of questions on similar subjects may account for some of the differences between samples. On the other hand, there are many advantages to using such data for cross-cultural comparisons. One is that the high cost of setting up similar protocols in different countries is reduced.
The factors investigated were the same for both surveys. They included the consumption of licit and illicit drugs, health, family, social integration, self-perception, and suicidal ideas.
In France the survey was conducted under the heading of adolescent health (Choquet et al., 1988). The Quebec survey pertained to the general population of youth aged 15 and over. From within this group, a cohort of 15- to 19-year-olds was chosen from the region of Rimouski, an area similar to the one studied in France (Kovess & Choquet, 1989). The characteristics of the survey as well as the instruments and population studied are summarized in Table 1.
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Comparing France and Quebec had advantages. The language spoken is the same, whereas sociocultural backgrounds differ, allowing comparisons.
Instruments
The wording of the question on suicidal ideation was, for France, "J'ai pense au suicide," which could be translated as "I have had suicidal thoughts" or "I have thought about suicide." Possible answers were never, rarely, fairly often, or very often, and the period of time considered was one year. It followed questions on being bored and having the blues, and implies that the suicidal thoughts concerned one's self. For Quebec, the question was "Avez vous pense a mettre fin a vos jours?" which has been translated as "Have you thought about ending your own life?" The period of time considered was one week.
In spite of the fact that the time factor imposed was different in the two studies, we have tried to create a basis for comparison by grouping together fairly often and very often in the French study, and sometimes, often, and very often in the Quebec study. Quebec youth who sometimes, often, or very often thought about suicide during the preceding week had presumably thought about it before (except in special cases). The French youth who reported having suicidal thoughts fairly often or very often presumably had these thoughts shortly preceding the survey.
Only the ratio of youth with suicidal ideas to those without suicidal ideas (SI/WSI) within each country were compared. The data were analyzed on VAX using SAS. For each of the countries, the SI and WSI groups were compared using the chi-square test (Pearson, or Fischer when the cohorts were small), with gender adjustment (Boyd and Doll).
RESULTS
Frequency of Suicidal Ideation
Among French adolescents, 5% of the boys and 12% of the girls frequently (fairly often or very often) thought about suicide during the preceding 12 months. Among the Quebec youth, the proportion of those who thought about suicide (at least once) during the week preceding the survey was 10% for the boys and 12% for the girls. Thus, there was little difference according to gender in Quebec (girl/boy ratio = 1.2), whereas the difference was quite noticeable in France (girl/boy = 2.4). Suicidal ideation was not linked to the family's socioeconomic status, nationality, or the mother's profession in either Quebec or France.
Suicidal Ideation and Drug Consumption
In both countries, there was a link between suicidal ideation and drug consumption. Thus, youth with suicidal ideas smoked more (SI/WSI = 1.4 in France, 1.5 in Quebec), used more psychotropic medicine (SI/WSI = 2.3 in France, 3.6 in Quebec), and more frequently used illicit drugs (SI/WSI = 4.9 in France, 2.0 in Quebec). These ratios persisted after gender adjustment. It should be noted that the link between SI and alcohol consumption was significant in Quebec (SI/WSI = 3.6) but not in France (SI/WSI = 1.2), where regular alcohol intake is culturally accepted, especially in rural areas. On the other hand, in France, SI was linked to repeated bouts of drunkenness (SI/WSI = 2.6), a more "addictive" form of alcohol consumption.
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Suicidal Ideation and Self-Perceived Health
In France and Quebec, SI was significantly linked to reported somatic symptoms, especially insofar as functional and affective disturbances were concerned. Thus, those adolescents with SI more frequently considered themselves to be in mediocre health (SI/WSI = 3.4 in France, 1.6 in Quebec) and to have more sleep disturbances (SI/WSI = 3.4 in France, 2.9 in Quebec). They complained more frequently of tiredness (SI/WSI = 2.0 in France, 2.4 in Quebec). They also slept less, although SI/WSI ratio was not as great as for the more "subjective" variables (1.7 in both countries). They considered themselves to be more depressed (SI/WSI = 5.7 in France, 4.2 in Quebec), more high-strung (SI/WSI = 2.3 in France, 4.3 in Quebec), and more often bored (SI/WSI = 3.1 in both countries). These findings persisted after gender adjustment.
Suicidal Ideation and Self-Perception
Youth who often had suicidal ideas (or who had them in the week preceding the survey) reported themselves to be more pessimistic, more jittery, sadder, more labile, more easily upset, and less able to concentrate. In spite of the variations in the wording of the questions (which may partially explain the differences), there was a striking similarity in the SI/WSI ratios in the two countries. Concerning TABULAR DATA OMITTED pessimism, SI/WSI was 3.3 in France and 3.9 in Quebec; for sadness it was 2.4 and 2.7, respectively. This depressive tonality was also present in the area of affective dysfunction. SI/WSI was 3.2 in France and 3.4 in Quebec in regard to feeling edgy, 1.5 and 1.4 respectively for lability, and 1.3 and 1.5 for difficulty concentrating. This feeling of internal tension is in keeping with being high-strung. Again, these findings persisted after gender adjustment.
Suicidal Ideation and Life-Style
There was no link between life-style (e.g., sports, peer activities) and SI. On the other hand, the nature of intrafamily relations had a definite effect on SI in both countries (SI/WSI = 1.7 in France, 2.6 in Quebec), which held true after gender adjustment.
Further, address changes were more frequent for adolescents with suicidal ideas than for those without, but the link was only statistically significant in France, where moving is culturally less frequent. Death or illness of a close friend or family member was reported more often by French youth, but was linked to SI only in Quebec.
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DISCUSSION
Both in Quebec and in France, the presence of suicidal ideation was an indicator of a more general state of malaise, as well as poorer health and self-perception. The questions concerning ideation thus brought a risk group into the foreground, enabling greater understanding of the types of risks that are involved. In fact, youth with SI seem to be vulnerable not only to acting-out (Choquet, 1986), but also to drug abuse (Kandel, 1989; Wright, 1985). While several studies have indicated that depressive youth are especially vulnerable to suicide attempts (Pfeffer, 1981; Lester & Gatto, 1989), few studies have dealt with the question of depression and suicidal ideation. It is important to note that most of the personal variables associated with ideation (Choquet & Menke, 1990; Paykel et al., 1974; Goldney et al., 1989) are the same as those associated with suicide attempts (Spirito et al., 1989).
There is a divergence of results according to gender in France, contrary to what has been observed in Quebec and in the U.S. (Kandel, 1989). This is true not only concerning SI, but other behaviors or troubles as well, such as drug consumption, lability, functional difficulties, and self-depreciation (Choquet et al., 1988). French youth therefore clearly differ from their counterparts in the U.S., where there is less contrast between the genders (Kovess & Choquet, 1989).
Youth in both Quebec and France who reported suicidal ideation were characterized by complaints regarding their health (especially nonspecific complaints such as tiredness, mediocre health, boredom). Using more complex evaluation scales, other researchers (e.g., Goldney et al., 1989; Paykel et al., 1974) have confirmed this link between SI and somatic symptoms.
Symptoms of depression (reported depressiveness, sleep disorders) were strongly linked to SI. Other researchers have also found this link, even when they feel that depression and SI are systematically associated (Kandel, 1989; Goldney et al., 1989; Pfeffer, 1981). It is interesting to note that the "objective" variable concerning sleep (number of hours) was less pertinent than the subjective variable concerning reported feelings about personal health. This would seem to suggest that malaise is more closely linked to psychological factors than to lifestyle factors.
A link between illicit drug consumption and SI was found for both countries, but was especially strong in France (SI/WSI = 4.9), where experimenting with drugs is not as frequent as in Canada. This association is confirmed by other studies (Kandel, 1989; Wright, 1985; Spirito et al., 1989). According to Kandel, drug use is a possible means of fighting off depression. Therefore, drug consumption and SI could both be considered symptoms of depression.
Use of psychotropic medicine, more frequent among youth with suicidal ideation than those without, pinpoints the risk of possible acting-out. In the study by Davidson and Philippe (1986), approximately 50% of the adolescents who attempted suicide did so with medicine for which they had prescriptions. Considering that 29% of French youth with SI have taken some form of psychotropic medicine, the risk is far from negligible.
The role of alcohol in the suicidal process warrants special attention. In France, where regular alcoholic intake is part of a socially accepted way of life, it is not associated with SI. However, a connection has been found in the U.S. and Canada (Wright, 1985). On the other hand, "addictive" use of alcohol is associated with SI (Choquet, 1986), as is regular alcoholic intake for girls (Choquet & Menke, 1990).
The link between regular cigarette smoking and SI needs to be more deeply explored. Use of tobacco is more widespread among suicide attempters (see Paykel et al., 1974), but this has rarely been dealt with in international studies due to the fact that it is not considered to be as serious a problem as drug and alcohol consumption.
The link between attempted suicide and self-perception has been widely studied; hopelessness, impulsive behavior, psychological rigidity, and inability to cope are often noted (see Spirito et al., 1989). In the present study, the following traits were found among those with suicidal ideation: edginess, inability to concentrate, and emotional instability. These have been previously noted in an adult population (Paykel et al., 1974).
Studies of SI (Wright, 1985; Welleman & Welleman, 1988; Salmons & Harrington (1984); Kandel, 1989) confirm the results of most studies on suicide attempters indicating the predominance of deteriorated family relations (Spirito et al., 1989; Pfeffer, 1981), as well as outright family pathology (Carlson & Cantwell, 1982). This dissatisfaction with family relationships, which was found for both French and Canadian youth with SI, confirms the hypothesis of a lack of family cohesion. However, it does not help us determine whether the fault lies in parental aggressivity or lack of communication (or both). A better understanding of family dynamics in relation to suicidal ideation is needed.
In neither of the studies was a link found between sports or peer activities and SI. Little has been written on the subject of extracurricular activities in this regard, mainly because researchers have been more concerned with the psychiatric rather than the sociological aspects of the problem. On the other hand, peer relationships have been studied extensively (Spirito et al., 1989; Kandel, 1989). Emotional isolation has been found to be greater among youth with SI (Spirito et al., 1989), although results have been inconsistent. According to Kandel (1989), youth with SI feel they can count on their friends more readily than on their parents. They take part in the same amount of group activities as their peers without SI.
Stressful life circumstances (death, illness, moving) were also found among youth with SI and thus point out the relative importance of such situations, even for those who do not attempt suicide. However, the link between moving and SI was significant only for French youth (where, culturally, changing homes is felt as a loss of one's anchorage point). In Quebec, moving within one town or even from one town to another is part of the life-style. However, illness and death were linked to SI only in Quebec, not in France, where the system of social care in cases of illness or death a relative offers more protection.
Implications for Prevention
Too often those concerned with prevention assume that suicidal ideation among adolescents is due to precarious national economic and societal conditions (e.g., high unemployment). The results of the present research tend to refute this view because the factors associated with suicidal ideation were similar in both countries despite their socioeconomic differences.
In order to prevent suicidal behavior among adolescents, it is of utmost importance to address the significance of family relations (Welleman & Welleman, 1988; Monck & Graham, 1989) and to be aware of early risk indicators such as licit and illicit drug consumption (especially tobacco and psychotropic medicine), affective and behavioral disorders (Carlson & Cantwell, 1982), and lability. Thus, both in France and Quebec, it is necessary for all health care professionals to be aware of these warning signs.
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