Suicide and Life-Threatening Behavior 35(4) August 2005 425

2005 The American Association of Suicidology

Adolescent Suicidality: Who Will Ideate,

Who Will Act?
Ted R. Miller, PhD, and Dexter M. Taylor, PhD

Responses to the 1999 Youth Risk Behavior Survey including suicide ide-
ation, attempt, medically treated attempt, and six problem behaviors were ana-
lyzed. Youth across the spectrum ideated. Overwhelmingly, the 17% of youth with
more than three problem behaviors were the youth who acted; they accounted for
60% of medically treated suicidal acts. Compared to adolescents with zero prob-
lem behaviors, the odds of a medically treated suicide attempt were 2.3 times
greater among respondents with one, 8.8 with two, 18.3 with three, 30.8 with
four, 50.0 with five, and 227.3 with six. A count of problem behaviors offers a
reliable way to identify suicide risk.

Adolescent suicide is a complex, often puz-
zling public health crisis. Suicide and suicide
attempt are epidemic among adolescents aged
1418 years in the United States, the third
leading cause of death (National Center for
Injury Prevention and Control [NCIPC],
2002). Unlike most adolescent injury risks,
suicide risk has been rising over the last de-
cade (Zametkin, Atler, & Yemini, 2001).
Many correlates of adolescent suicide
are known. They include psychosocial factors
such as household dysfunction or stressful
life events (Fergusson & Lynskey, 1995; King
et al., 2001; Reifman & Windle, 1995; Rein-
herz et al., 1993; Zametkin et al., 2001); psy-
chiatric factors, including depression, anxiety
disorders, and schizophrenia (Brent et al.,
1986; Gould et al., 1998; Shaffer, 1988); and
health-threatening problem behaviors such
Dr. Ted Miller and Dr. Dexter Taylor
are with the Pacific Institute for Research and
Evaluation in Calverton, Maryland.
This research was supported by the Na-
tional Institute of Mental Health Grant Number
1-R01-MH60622.
Address correspondence to Dr. Ted Miller,
Pacific Institute for Research and Evaluation,
11710 Beltsville Dr., Suite 300, Calverton, MD
20705-3102; E-mail: Miller@pire.org.
as violent behavior, excessive drinking, regu-
lar smoking, substance abuse, and high-risk
sexual behavior (Fergusson & Lynskey, 1995;
King et al., 2001; Woods et al., 1979).
The association between suicidal be-
havior and health-threatening problem be-
haviors has been well documented (Cohen-
Sandler, Berman, & King, 1982; Patton et al.,
1997; Walter et al., 1995; Woods et al., 1979;
Zung, Broadhead, & Roth, 1993). One re-
cent report (Powell et al., 2001), for example,
found binge drinking 3 or more days in the
past year increased the odds of a nearly lethal
suicidal attempt by more than twofold; odds
ratios, however, did not remain significant
after controlling for other demographic vari-
ables and alcohol consumption measures. Ag-
gressive behavior among both males and fe-
males is an important risk factor for suicidal
behavior (Garrison, McKeown, Valois, &
Vincent, 1993). In addition, disturbed eating
behavior correlates with depression and sui-
cidal behavior, and other health-compromis-
ing behaviors (Neumark-Sztainer, Story, Dixon,
& Murry, 1998; Viesselman & Roig, 1985).
Although several epidemiological and
clinical studies have documented health-
threatening problem behaviors that correlate
with suicide ideation and attempt (Beautrais,
426
2000; King et al., 2001; Shaffer, 1988; Woods
et al., 1979), few have rigorously examined
how concurrent health-threatening problem
behaviors, in particular, impact the likelihood
of suicide ideation and attempt. Research
that considers the cumulative effect of prob-
lem behavior on suicidal acts tends to include
psychiatric and psychosocial factors as well as
problem behavior (e.g., Reifman [Reifman &
Windle, 1995] and Garnefski [Garnefski &
Diekstra, 1997]). Consequently, appreciation
of the specific role problem behaviors play in
the relationship is obscured.
Children and adolescents who concur-
rently exhibit two or more problem behav-
iors often are termed multiple-problem youth
(Elliott, Huizinga, & Menard, 1989; Farrell,
Danish, & Howard, 1992). A substantial
body of literature, much of it motivated by
Jessor and Jessors Problem-Behavior Theory
( Jessor & Jessor, 1979), describes the ten-
dency for problem behavior to co-occur
during adolescence. Several researchers, for
example, have shown substantial positive cor-
relations among problem behaviors such as
alcohol use, cigarette smoking, illicit drug
use, delinquent behavior, and precocious sex-
ual intercourse in adolescent youth (Adger,
1992; Donovan & Jessor, 1985; Donovan,
Jessor, & Costa, 1988; Jessor & Jessor, 1979).
Through factor analysis, researchers have
shown that the interrelations of problem be-
haviors among adolescent youth are repre-
sented by a common factor, described by
Donovan and Jessor (1985) as a syndrome
of problem behavior.
The relationship between multiple
problem behaviors and suicidal behavior,
however, has not been adequately addressed
in this research tradition. Our research ex-
tends understanding of adolescent suicidality
by testing whether the co-occurrence of
health-threatening problem behaviors can be
identified as a unique risk factor for suicide
ideation and attempt. We investigated whether
multiple-problem youth are at significant risk
for suicide ideation and attempt and whether
suicide risk increases with each additional
health-threatening problem behavior. We
hypothesize that the number of concurrent
Adolescent Suicidality
problem behaviors exhibited by an adolescent
offers a straightforward, reliable way to iden-
tify adolescents most at risk for suicidal acts.
METHODS
Study Population
The study population was drawn from
the 1999 Youth Risk Behavior Survey (YRBS),
which is a national school-based survey es-
tablished by the Centers for Disease Control
(CDC) to monitor the prevalence of health-
risk behaviors among youth in the United
States. The CDC used a three-staged cluster
design to collect data for the YRBS. During
the first stage, large counties or groups of
smaller, adjacent counties were sampled.
Schools were sampled during the second
stage; schools were selected while accounting
for the effect of school enrollment size. Dur-
ing the final stage, classes from grades 912
were randomly selectedone or two classes
from each school. Adolescents in 144 schools
completed the questionnaires. The school re-
sponse rate and the student response rate
were 77% and 86%, respectively (CDC,
2000, June 9).
Brener, Collins, Kann, Warren, and
Williams (1995) measured the test-retest re-
liability of the 1992 YRBS by administering
the questionnaire twice to 1,679 high school
students, grades 712. After a 14-day inter-
val, the YRBS was found to have good to ex-
cellent reliability for more than 70% of its
items. Items concerning suicide attempts in
the past year, which are of primary interest
in our report, had Kappa coefficients from
0.602 to 0.823.
The YRBS is a self-report instrument.
To protect students privacy, the surveys were
completed on an anonymous and voluntary
basis. The questionnaire was self-adminis-
tered; students recorded their responses di-
rectly onto an answer sheet. The question-
naire included 92 multiple-choice questions.
We analyzed six health-threatening problem
behaviors measured by the YRBS: violent be-
havior, binge drinking, disturbed eating be-
Miller and Taylor
havior, regular tobacco smoking, illicit drug
use, and high-risk sexual behavior. The YRBS
provided three suicide risk measures: ide-
ation, attempt, and medically identified at-
tempt in the past year.
Exclusions from Study Sample
Only respondents who answered items
about the presence or absence of each cate-
gory of health-threatening problem behavior
and the presence or absence of suicidal tend-
encies were included in the analysis. We ex-
cluded 299 nonrespondents on suicide at-
tempts, 40 nonrespondents on suicide ideation,
and 830 nonrespondents on at least 1 of the
6 problem behaviors; those excluded for non-
response about problem behaviors did not
differ significantly from other respondents in
suicide attempt and medically treated suicide
attempt rates.
For some respondents, we chose to in-
fer the correct response to skipped follow-up
items. For example, some respondents re-
ported they never had sexual intercourse and
subsequently skipped all follow-up questions
concerning sexual activity and related conse-
quences. We recoded the missing follow-up
responses as no. Similarly, if respondents
reported they did not engage in suicide ide-
ation and skipped all follow-up items con-
cerning specific suicidal behavior, we recoded
the missing responses as no. Other respon-
dents reported suicide attempts but did not
respond to the question concerning suicide
ideation, which we coded as yes.
Definitions
Violent Behavior. Respondents were
considered violent if they were involved in
two or more physical fights during the past
12 months, carried a gun during the past 30
days, or both.
Binge Drinking. Respondents were
considered binge drinkers if they reported
having five or more drinks of alcohol in a
row, that is, within a couple of hours, on 1 or
more days during the past 30 days.
427
Disturbed Eating Behavior. Respon-
dents were considered to have disturbed
eating behavior if they went without eating
for 24 hours or more to lose weight or to
keep from gaining weight during the past 30
days, vomited or took laxatives to lose weight
or keep from gaining weight during the last
30 days, or both.
Regular Tobacco Smoking. Respon-
dents were considered smokers if they
smoked cigarettes for 3 or more days during
the past 30 days; smoked a cigar, cigarillo, or
a little cigar 1 or more days during the past
30 days; or both.
Illicit Drug Use. Respondents who
during the past 30 days used marijuana, any
form of cocaine (e.g., powder, crack, or free-
base), or inhalants to get high (e.g., sniffed
glue, breathed aerosol, or inhaled paints or
sprays) were considered illicit drug users, as
were respondents who during their lifetime
used heroin, methamphetamine, or a needle
to take any illegal drug.
High-Risk Sexual Behavior. High-risk
sexual behavior was defined as one or more
of the following behaviors: had sex for the
first time before age 14; had sexual inter-
course with four or more people during life-
time; had 3 or more sexual partners during
the past three months; had sexual intercourse
without a condom during last encounter; had
been pregnant or had gotten someone preg-
nant; and used high-risk or unreliable birth
control methods during last encounter, spe-
cifically, withdrawal, no method, or uncer-
tainty about which method was used.
Multiple-Problem Youth. Respondents
who exhibited three or more health-threat-
ening problem behaviors were considered
multiple-problem youth.
Suicide Ideation, Suicide Attempt, and
Medically Treated Suicide Attempt. We used
two questions to define suicide ideation, sui-
cide attempt, and medically treated suicide
attempt: (1) During the past 12 months, did
you ever seriously consider attempting sui-
cide? and (2) If you attempted suicide dur-
ing the past 12 months, did any attempt re-
sult in an injury, poisoning, or overdose that
had to be treated by a doctor or nurse? Sui-
428
cide ideation was defined as a yes response
to the former question. Because the latter
question offered yes, no, or did not at-
tempt suicide as possible responses, it was
used to define all respondents who attempted
suicide (yes or no responses) and to de- the 15,285 male (49%) and female (51%) re-
fine a subset of respondents who made a
medically treated suicide attempt (yes re-
sponses).
Statistical Analysis
Logistic regression models were cre-
ated with seven dichotomous variables that
represented the total number of health-
threatening problem behaviors, 0 to 6, re-
ported by each respondent. Covariates based
on demographic variables were entered into
the regressions to strengthen the models.
The covariates allowed us to adjust odds ra-
tios for suicide ideation and attempt to ac-
count for the effect of the respondents age,
race, and gender. The referent category was
White 18-year-old males with zero health-
threatening problem behaviors. Adjusted odds
ratios and 95% confidence intervals were ob-
tained from logistic regression models and,
because attempted suicide is a relatively rare
event, were interpreted as good estimates of
relative risk of suicide ideation, suicide at-
tempt, and medically treated suicide attempt.
Weighted tabulations and regressions were
conducted with STATA runs that accounted
for the sample design when computing stan-
dard errors.
Several additional logistic regression
models were run to test whether the number
of health-threatening problem behaviors is a
stronger predictor of suicidality than the na-
ture of health-threatening problem behav-
iors. As with the models previously described,
age, race, and gender were covariates, and sui-
cide ideation, suicide attempt, and medically
treated suicide attempt were outcome vari-
ables. We also tested the residual explanatory
power of each health-risk behavior in a series
of logistic regressions that included a specific
health-risk behavior, the number of health-
risk behaviors (16), and demographic infor-
mation.
Adolescent Suicidality
RESULTS
Characteristics of Study Population
In this study, we limited our sample to
spondents who were aged 14 and older. The
CDC sampled schools with large numbers of
African American and Hispanic students at
higher rates than other schools to enable sep-
arate analyses of these ethnic groups (CDC,
2000, June 9). Thirty-five percent of un-
weighted respondents were White, 28%
were African American, 27% were Hispanic,
4% were Asian American, 2% were Native
American, and 4% were of mixed heritage or
did not respond to the item. The weighted
percentages of respondents in each age group
were 9% aged 14 years, 25% aged 15 years,
28% aged 16 years, 24% aged 17 years, and
14% aged 18 years or more. Among adoles-
cents in this sample, 22.0% reported suicide
ideation, 7.7% reported a suicide attempt,
and 2.3% reported a medically treated sui-
cide attempt in the past year. The prevalence
of health-threatening problem behavior was
very high among those respondents with sui-
cidal behaviors and progressively increased as
the severity of suicidal behavior increased
(Figure 1). At least 45% of respondents re-
porting a medically treated suicide attempt
reported each health-threatening problem
behavior, with more than 70% reporting
smoking, illicit drug use, and high-risk sexual
behavior.
We examined subsets of respondents
identified by the number of problem behav-
iors they exhibited. As Figure 2 shows, the
percentage of respondents who engaged in
suicide ideation, suicide attempt, or medi-
cally treated suicide attempt during the past
year sharply increased with each additional
health-threatening problem behavior. In-
deed, 47% of respondents who reported hav-
ing all six health-threatening problem behav-
iors attempted suicide in the year before the
survey.
The percentage distribution of prob-
lem behaviors among respondents with vary-
ing severity of suicidal behavior shows the
Miller and Taylor 429

Figure 1. Prevalence of health-threatening problem behaviors among respondents by suicidal behavior.

most severe suicidal acts are disproportion-
ately committed by respondents with four or
more problem behaviors (Table 1). Among
respondents with 02 problem behaviors, the
relative proportion of respondents who en-
gage in suicidal acts decreases as the severity
of the act increases. Among respondents with
46 problem behaviors, however, the relative
proportion of respondents who engage in
suicidal acts increases as the severity of the
act increases. Although adolescents with 46
concurrent problem behaviors are a small
portion of the sample, these adolescents ac-
count for most of the suicidal acts. The 17%
of youth with four or more problem behav-
iors account for 60% of the medically treated
suicide attempts. Further, the 7% of youth
with five or more problem behaviors account
for 33% of the medically treated suicide at-
tempts.
Logistic Regressions Predicting
Suicidal Acts
Table 2 describes logistic regression
models that suggest the mere number of

Figure 2. Prevalence of suicidal behavior among respondents who exhibit 06 health-threatening problem behaviors.
TABLE 1
Percentage and 95% Confidence Intervals for Suicidal Behavior by Severity of Suicidal Act and Number of Problem Behaviors

Problem Behaviors
Severity of
Suicidal Act 0 1 2 [02] [46] 3 4 5 6

All youth 33.6 22.3 14.4 12.8 10.2 5.5 1.2

[70.3] [16.9]
(31.036.2) (20.724.0) (13.415.5) (11.314.4) (09.011.6) (04.406.8) (01.001.5)
Ideation only 21.9 23.5 13.8 15.9 16 7.6 1.3
[59.2] [24.9]
(18.625.7) (20.027.4) (11.116.9) (12.819.7) (12.819.9) (05.410.5) (09.301.8)
Untreated attempt 9.7 21.8 18.3 16.8 16.3 14.3 3
[49.6] [33.6]
(07.213.0) (15.130.3) (13.324.6) (13.021.2) (11.322.9) (09.021.9) (01.605.5)
Treated attempt 3.9 5 11.5 19.1 25.3 19.2 16
[20.6] [60.4]
(01.908.1) (02.609.2) (06.718.9) (12.428.2) (16.337.1) (12.428.5) (09.126.7)
Miller and Taylor 431

TABLE 2
Odds Ratios and 95% Confidence Intervals from Logistic Regressions
that Predict Suicidality
Suicidal Behavior
Medically
Treated
Problem Behaviors Ideation Attempt Attempt

A. Predicting Suicidality with the Number of Problem Behaviors Exhibited

by a Youth
0 1.0 1.0 1.0
1 2.2 (1.72.8) 3.6 (2.55.2) 2.3 (1.05.6)
2 2.6 (2.13.3) 6.5 (4.69.1) 8.8 (3.621.7)
3 3.8 (2.85.2) 8.4 (5.512.7) 18.3 (7.743.7)
4 5.5 (3.87.8) 11.7 (7.119.4) 30.8 (12.079.7)
5 7.4 (4.811.3) 24.0 (13.742.2) 50.0 (16.2154.4)
6 13.4 (7.224.7) 60.2 (29.6122.6) 227.3 (75.7682.3)
B. Predicting Suicidality with All Risk Behaviors Entered Simultaneously
Behavior not present 1.0 1.0 1.0
Binge drinking 1.0 (0.81.2) 0.8 (0.61.0) 1.3 (0.82.0)
Tobacco smoking 1.4 (1.11.7) 1.7 (1.32.2) 2.0 (1.03.7)
Illicit drug use 1.8 (1.32.4) 2.3 (1.73.1) 2.2 (1.23.8)
High-risk sex 1.5 (1.21.9) 2.2 (1.53.3) 5.0 (2.98.7)
Violent behavior 1.6 (1.31.9) 1.8 (1.32.5) 2.0 (1.32.8)
Disturbed eating 2.4 (1.92.9) 3.1 (2.43.9) 2.8 (2.03.9)
C. Predicting Suicidal Behavior with Models that Include One Specific Risk Behavior
and the Number of Problems Exhibited by a Youth
Behavior not present 1.0 1.0 1.0
Binge drinking 0.6 (0.50.8) 0.4 (0.30.5) 0.5 (0.30.8)
Tobacco smoking 0.9 (0.61.1) 0.9 (0.61.2) 0.8 (0.41.5)
Illicit drug use 1.1 (0.91.4) 1.1 (0.81.6) 0.8 (0.41.6)
High-risk sex 1.0 (0.81.2) 1.3 (0.81.9) 2.8 (1.55.2)
Violent behavior 1.1 (0.91.3) 1.0 (0.71.4) 0.9 (0.61.5)
Disturbed eating 1.6 (1.32.0) 1.7 (1.32.2) 1.2 (0.91.7)

Odds ratios adjusted for age, race, and gender.

health-threatening problem behaviors exhib- included dichotomous measures of each spe-

ited by an adolescent increases the relative
odds of suicidal behavior. Compared to those
with no problem behavior (odds = 1.0), the
odds of a medically treated suicide attempt
rose most sharply to 227.3 with six problem
behaviors. Similar logistic regressions on the
subset of respondents who reported suicide
ideation showed that suicide attempt risk in-
creased significantly with the number of con-
current health-threatening problem behav-
iors, especially for those with 46 problems.
We ran regressions that simultaneously
cific health-threatening behavior and the pre-
viously identified demographic controls. Each
risk behavior except binge drinking was asso-
ciated with suicidal acts across all levels of
severity (see the middle portion of Table 2).
Binge drinking was negatively associated with
suicide attempt and was not associated with
suicide ideation or medically treated suicide
attempt.
We compared models that describe the
respondents specific problems (nature-based)
with models that count the respondents
432
number of problems (number-based). To com-
pare the models we calculated the mean dif-
ference between the predicted probabilities
of a suicidal act and the actual occurrence of
suicidal acts found in each modelan event
equaled 1 and a nonevent equaled 0. Al-
though both types of models were statisti-
cally significant and similarly strong predic-
tors of suicidality, number-based models
identified factors that produced odds ratios
which far exceeded odds ratios produced by
nature-based models. The final series of lo-
gistic regressions presented in the last por-
tion of Table 2 revealed that, controlling for
the number of problem behaviors, only dis-
turbed eating behavior and high-risk sexual
behavior were significant independent pre-
dictors of greater suicide risk.
The association between binge drink-
ing and suicidality was more complex. Binge
drinking had a significant negative coefficient
when predicting suicide risk. This simply
may mean binge drinking is associated with a
less steep rise in suicide risk than the other
behaviors. We tested the effect of binge
drinking on suicidality after controlling for
demographics but not for other health-risk
behaviors. These regressions showed binge
drinking, in fact, is associated with an in-
creased likelihood of suicide ideation (2.0,
95% CI 1.72.4), suicide attempt (2.3, 95%
CI 1.83.0), and medically treated suicide at-
tempt (4.5, 95% CI 2.77.5).
Limitations
Although this study uses nationally
representative data, it has several limitations.
First, because the data were collected concur-
rently, we cannot determine whether health-
threatening problem behaviors are anteced-
ents or consequences of suicidal behavior.
Second, the YRBS omits school dropouts and
absent students, two groups more likely to
engage in health-threatening problem behav-
iors than students who participated in the
survey. Further, these data are limited to
youth attending grades 912. However, com-
parisons we ran with data from the 1999 Na-
tional Household Survey on Drug Abuse,
Adolescent Suicidality
which reaches all youth, suggest the YRBS
accurately represents the percentage distri-
bution of drinking, drugging, and smoking
among American youth. Recent research also
suggests failing to collect data from absent
students does not significantly alter risk esti-
mates (Guttmacher, Weitzman, Kapadia, &
Weinberg, 2002). Third, some respondents
were excluded from our analysis due to non-
response to measures of health-threatening
behaviors and suicidal behaviors. Finally,
these data are based on a self-report instru-
ment and, as such, do not include suicide fa-
talities; hence, they cannot be generalized to
describe all suicidal acts among adolescents.
RECOMMENDATIONS
Our analyses answered the questions
posed in the title of this paper. Who will ide-
ate? Youth across the spectrum ideate. Who
will act? Overwhelmingly multiple-problem
youth engage in suicidal acts. Those answers
have strong implications for suicide preven-
tion program design, suicide treatment pro-
tocols, and the youth suicide research agenda.
Implications of Research for Suicide
Prevention Programs
It is quite clear that youth at serious
risk for suicide can be targeted fairly accu-
rately with a few simple screening questions.
With scarce resources, programs can be tar-
geted narrowly and still reach 80% of those
at high risk. Although ideation is broadly
spread across the adolescent population, the
shift from ideation to action is highly con-
centrated among multiple-problem youth.
Youth with multiple high-risk behav-
iors are serious suicide risks. If health provid-
ers, friends, teachers, or parents know a girl
is anorexic or bulimic, smoking, and drink-
ing/drugging, for example, they need to as-
sume that she is suicidal. It often is more
practical to observe objective behavioral
problems than quiet depression or suicidal
thoughts. The two walk together; so should
treatment protocols. Detecting the objective
Miller and Taylor
problems should automatically trigger inter-
vention to reduce suicide risk. Caregivers
need to know this. Providers need to educate
them, refer at-risk youth for counseling, and
actively manage the intervention process.
In psychological and public health lit-
erature, multiple-problem youth have been
identified as at-risk youth for several years
(Elliott et al., 1989; Jessor & Jessor, 1979).
Because problem behaviors tend to occur
concurrently during adolescence, research on
multiple-problem youth often advocates screen-
ing adolescents for other health-threatening
problem behaviors whenever a single prob-
lem behavior is identified (Donovan & Jessor,
1985; Donovan et al., 1988). Few, however,
advocate screening for suicidal behavior. Our
research is a clarion call for screening for sui-
cide risk among youth with multiple prob-
lems.
Implications of Research for Suicide
Treatment Protocols
Likewise, our research suggests screen-
ing for other health-threatening problem be-
havior in youth suicide treatment protocols.
Moreover, screening for health-threatening
problem behaviors among suicidal youth should
not be limited to gender-typical problem be-
haviors. Disturbed eating behavior, for exam-
ple, is typically associated with adolescent fe-
males. In our research, however, 36% of male
adolescents who made a medically treated sui-
cide attempt also exhibited disturbed eating
behavior. Similarly, violent behavior is typi-
cally associated with adolescent males. In our
research, however, 37% of female adoles-
cents who had a medically treated suicide at-
tempt in the past year also engaged in violent
behavior during the past year.
The linkage between multiple-prob-
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Manuscript Received: February 5, 2004
Revision Accepted: November 21, 2004