The present study examined the prevalence of suicidality and associated factors among Japanese adolescents. The study was characterized by nationally representative large-scale data, covering urban, suburban, and rural areas in Japan; it analyzed associated factors in terms of general information about the respondents, their feelings, family function, bullying, and various stressors. The overall prevalence of suicidal ideation and suicide attempts among Japanese adolescents was 25.7% and 5.4%, respectively; those rates are similar to ones observed in Western countries [4,7]. School grade level and geographic regions did not appear to be associated factors. However, a number of characteristics and perceptions appeared to have an association with suicidality in this sample. Prior perceived cyberbullying and stressors about the relationship with parents were particularly important factors.
The strength of this cross-sectional survey was that we simultaneously analyzed various possible associated factors of adolescents’ suicidality, including environmental factors and their stressors; experience of cyberbullying was identified as the most significant associated factor. According to the Japanese government’s official announcement about the causes of adolescent suicides, poor school academic records and stressors about the academic course were the most significant causes (9.9% of suicide cases were considered as having those conditions as a possible cause) [19]. Although 8.8% of completed suicides were related to a stressful relationship with parents; the overall bullying rate as a possible cause was only 1.8%. It is imperative that school health providers observe this discrepancy between the government’s official announcement and our results to develop and optimize preventive interventions.
Associations between bullying (cyber or school) victimization and suicidal behavior have been reported over the past decade; the growing number of reports could reflect great concern [20-24]. Psychological distress by cyberbullying is more severe than that with school traditional bullying: it is more anonymous and pervasive, and it can happen anytime and anywhere [23,24]. Based on the intensity of threats and individual vulnerability of the victims, cyberbullying may directly result in increased depression and suicidal behavior [21]. In the present study, the definition of cyberbullying was not determined, thus it seemed to self-reported perception of cyberbullying. However, 1.8% of adolescents related the experience of cyberbullying: among them, 19.9% and 52.0%, respectively, had attempted suicide and had suicidal ideation. The association between level of Internet use and suicidal ideation or attempts was investigated in over 200,000 adolescents using a Web-based survey; participants with a higher Internet addiction risk reported significantly higher suicidal ideation or suicide attempts [22]. Use of the Internet is increasing as a communication vehicle among children; thus, guidance about cyberbullying should be provided in school health programs to prevent possible suicidal behavior.
Another striking factor for suicidality identified in the present study was stress related to parental relationships. This factor showed the second- and fourth-highest odds ratio as an associated factor among junior high and high school students, respectively. When participants were asked whether they had stress related to their relationship with parents, the meaning of that relationship with parents could be widely interpreted, including family support, family function, conflict with family, conversation, and other factors. Negative perceptions of family function or support have been reported as being a significant associated factor of suicidality in both community and clinical samples [7,9,11,25-29]. Samm et al. [29] observed that self-reported satisfaction with relationships in the family and good communication with parents reduced the likelihood of suicidal thoughts in a non-clinical sample of adolescents. Susukida et al. [11] reported that individuals who perceived love from caregivers during childhood had a significantly lower prevalence of lifetime suicidal ideation than individuals without such perceptions; this finding was independent of whether or not the individuals lived with both biological parents during childhood. Susukida et al. [11] suggested that regardless of family structure, perceived support from caregivers during childhood is an important correlate of lifetime suicidal ideation. Similarly, in clinical samples, family discord and negative relationships with parents have been found to be associated with increased suicide risk in depressed adolescents [25-27,29]. Furthermore, suicidal ideation of children is associated with suicidal depression of caregivers [28]. The evidence indicates that good relationships with parents lead to lower lifetime suicidal ideation. Thus, it is important for health providers to assess individual family function, which may be a key preventing factor for suicidal ideation or attempted suicide in adolescents.
A growing body of evidence suggests that help-seeking behavior may influence the prevention of suicidal ideation or attempted suicide in adolescents [30-32]. Help seeking is defined as the use of social networks or professionals to gain support in coping with suicidal ideation and attempted suicide [31]. Though friends and family members are likely to be the greatest support resources for adolescents with suicidality, the majority of young people and adolescents with suicidality do not seek help for their difficulties [33]. In the present study, reports of a low number of friends and limited conversation with families, were associated with a greater prevalence of suicidality. This may indicate the importance of friends and family as help-seeking resources. Furthermore, the adolescents consulted different resources about their stressors according to the type of stress. Our participants chose the Internet as a consulting resource for worries or stress about sexual identity, substance use, and relationships with parents. However, participants tended not to confide in their teachers as a consulting resource, indicating reluctance to undertake help-seeking behavior. Our respondents may have been concerned about confidentiality and stigma, which can prevent young people from seeking help. Two studies have used a school-based education program, including Internet-based cognitive behavioral therapy, to improve suicidality in young people: one study found a significant effect, but the other found no effect [34,35]. Such trials may be an effective way of helping young people access help-seeking behavior.
The present study has some limitations. Study results must be considered in the context of potential response bias inherent in our survey process. First, ideally suicidal ideation and attempts would be reviewed with two discrete questions. In our study, the participant’s responses for suicidal ideation and suicide attempts were listed in one answer column to minimize the invasive effects on participants. In Japan, some educational committees still have the perception that talking about suicide and its prevention in the classroom as an educational program might increase the possibility of suicide in a vulnerable child. For this reason, we were obligated to minimize questions pertaining directly to suicidality. However, the questionnaire for suicidality is not validated. Second, we did not perform structured diagnostic and cognitive interviews with the participants, and we did not ask about depressive symptoms in the questionnaire. Thus, we did not assess for depressive disorders, which may be associated with the development of suicide plans. Third, we did not evaluate socioeconomic status, such as income and education level, or the family structure of the parents and their children.
In conclusion, we found the prevalence of suicidal ideation and attempted suicide in Japanese adolescents to be 25.7% and 5.4%, respectively; those rates are similar to ones observed in Western countries [4,7]. We simultaneously investigated various possible associated factors of the children’s suicidality; we identified the experience of cyberbullying as the most significant associated factors. The relationship between children and their parents was also important in prevention efforts of suicidal behavior. Further research is needed about school- and home-based mental health education by health providers and families toward facilitating help-seeking behavior among adolescents.