Mediating effects of suicidal ideation in the relationship between psychological distress and non-suicidal self-injury among adolescents with major depressive disorder: The roles of sex and urban-rural status

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Mediating effects of suicidal ideation in the relationship between psychological distress and non-suicidal self-injury among adolescents with major depressive disorder: The roles of sex and urban-rural status

https://doi.org/10.21203/rs.3.rs-1852442/v2

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Background: Non-suicidal self-injury(NSSI) is a major public concern, and psychological distress(PD) has been found to be an important risk factor of NSSI. However, little is known about the mediating mechanism underlying this relationship. This study aimed at testing the mediating effects of suicidal ideation(SI) in the relationship between PD and NSSI among adolescents with major depressive disorder. Additionally, it's unclear if this effect exists or differs between sexes or urban-rural status.

Methods: A total of 428 Chinese adolescents with major depressive disorder(MDD) from 9 provinces across China completed self-reported questionnaires regarding PD, SI and NSSI.

Results: The SI mediated the relationship between PD and NSSI, and the estimated ratio of the total effect of PD that could be explained by mediation through SI was 33.59%. The ratio was higher in female adolescents with MDD (39.23%) than in males(18.05%), and it was higher in urban adolescents with MDD(43.35%) than in rural adolescents with MDD(15.55%).

Conclusions: Among adolescents with MDD, PD may influence NSSI behavior through SI. Interventions aimed at reducing NSSI associated with PD may be enhanced by efforts to mitigate SI, especially in females and urban adolescents.

psychological distress

suicidal ideation

NSSI

adolescent

mediating effects

The relationship of psychological distress to non-suicidal self-injury

Non-suicidal self-injury(NSSI) is described as someone inflicting direct bodily harm on themselves without suicidal ideation for a non-socially sanctioned reason^1–3. Cutting, scratching, hitting, and headbanging are common forms of NSSI². NSSI has become significant problem with high prevalence in adolescents and young adults⁴. A study based on non-clinical sample showed the NSSI exhibited a prevalence rate of 17.2% in adolescents⁵. Given the increasing prevalence of NSSI, the WHO has recognized the NSSI as one of the top five health threats in adolescents⁶. More seriously, the NSSI prevalence was higher in Chinese adolescents. In mainland China, Wan et al. found that 24.9% of the middle school students engaged in NSSI⁷, and a meta-analysis showed the prevalence of NSSI was 23.3% in middle and high school students⁸.

Researches systematically concluded the risk factors of NSSI⁹, including psychological distress(PD), encounter cyberbullying, and substance use¹⁰. Among them, PD received much more attention from researchers. PD refers to non-specific symptoms of stress, anxiety, and depression¹¹. Empirical research has provided extensive support for the role of PD in NSSI. Prospective study indicate that higher PD in adolescents may predict subsequent NSSI later in life¹². Preliminary physiology research indicated that people with NSSI have heightened activity to stressful life events^13,14. PD also influences the frequency of NSSI indirectly. According to a cross-sectional study in young adults, PD may exert indirect effects on the frequency of NSSI through rumination, cognitive reappraisal, and expressive suppression¹⁵. All these empirical studies have pinpointed that PD contributed to the development of NSSI.

Suicidal ideation as a mediator

SI refers to having thoughts of killing oneself. Suicidal ideation may act as a mediator in the relation between PD and NSSI, such that PD may precipitate a heightened risk for SI, and SI may also increase the risk of NSSI. PD as a predisposing risk factor of SI have been proposed in theoretical model. For example, the Interpersonal Psychological Theory of Suicide(IPTS), which explained the perceived burdensome, thwarted belongings can induce the suicidal ideation¹. Moreover, recently study found perceived burdensome and thwarted belongings can induce suicidal ideation through psychological distress¹⁶. Empirical study also found PD is one of the strongest risk factors of SI¹⁷. Survey in 12-nations among university students found a positive correlation between PD and SI(Eskin et al., 2016). Study conducted in Chinese undergraduate students also found the PD is significant associated with SI¹⁸.

Theoretical models have demonstrated the different reason for people with SI engage in NSSI. According to Interpersonal Psychological Theory of Suicide(IPTS), Joiner proposed that individuals who experienced SI would later engage in suicide when they obtain the capability for suicide through NSSI¹, which implies that people are more likely to engage in NSSI when they experienced SI. Empirical study also supports the IPTS theory. Among nonclinical sample, NSSI may serve as a stepping stone to suicide attempt and typically emerges prior to first suicide attempt¹⁹, and repetitive NSSI behaviors may assist individuals with SI to later complete suicide by reducing their pain sensitivity and fear^20,21. While some people make NSSI a short-term anti-suicide strategy. According to Suyemoto’s anti-suicide model, the NSSI represented a compromise to suicide and was used to relieve SI in a short term^22,23. This anti-suicide function made individuals a greater engagement in NSSI^24,25. Recently, a real-time monitoring study based on ecological momentary assessment(EMA) supports this view, it found the NSSI have short-term ameliorating effect on SI²⁶. All of these theoretical and empirical research have found adolescents with SI are vulnerable to NSSI.

The majority of the research has been in line with the notion that PD is related with SI, and SI is related with NSSI. To date, no previous studies have directly examined the mediating role of SI in the relationship between PD and NSSI.

The role of sex and urban

Mounting evidence from empirical studies conducted in community, school, and hospital samples have showed that SI differs in sexes. A school-based survey found Chinese female adolescents have higher SI than their male counterparts²⁷. Hospital samples included that drunk female adolescents were observed higher SI than male adolescents²⁸. The research also found the association between PD and SI was more pronounced in female adolescents²⁸. Being female and born at lower economic status were risk factors of NSSI in general adolescents²⁹. Though research have demonstrated the PD differs in sexes, whether sex difference affects the mediating role of SI in the association between PD and NSSI remains unknown. Further study to clarify the sex difference in adolescents with MDD was needed.

Study conducted in non-clinical sample found PD have rural and urban variation. Hwang et al. found migrants in Three Gorges Dam project found urban residents had a lower depression score than their rural counterparts³⁰. Study in nine countries of the former Soviet Union also found lower levels of urbanicity are associated with greater psychological distress³¹. The urban residence have higher psychological well-being³², while so far there is no direct evidence pertaining to whether the PD have urban-rural difference in adolescents with MDD. Urban-rural difference also exist in SI. Rural adolescents are more likely to have higher SI than urban adolescents^33,34. Given the rural adolescents in China have higher SI than their peers who live in urban, a separate analysis to detect the relationship between PD, SI, and NSSI was required.

The current study

Although previous studies have demonstrated the relationship between PD, SI and NSSI. They have been limited in several areas.

First, little study has examined the mediating role of SI in the relation between PD and NSSI in China, even fewer conducted in clinical sample. Cultural difference may exist in Chinese adolescents and western adolescents, for instance, Chinese college students have higher suicidal ideation than western adolescents³⁵, and NSSI were more prevalent in Chinese adolescents. It is important to examine how PD influence NSSI through SI in Chinese adolescents. Besides, clinical sample were more susceptible to NSSI and suicide, investigate the mechanism how PD influence NSSI is pivotal.

Second, among those researches, sociodemographic characteristics were not take into consideration, but female adolescents have higher frequency of NSSI than males, and meta-analysis found being female is a risk factor of NSSI in adolescents²⁹. While no study examined the mediating effects of SI between the relationship of PD and NSSI by sex and urban/rural status in clinical adolescents in China. Therefore, this study aimed at exam whether the mediating effects of SI in the relation between PD and NSSI exist and vary in different sexes. Thirdly, the SI have urban-rural difference, the rural adolescents in China reported higher SI than urban adolescents^29,34. Therefore, conduct a separated analysis in urban/rural area were needed.

Adolescence is a time for significant increase in physiological and psychological development, hence, investigating the mediating role of SI in the relation between PD and NSSI may help us understand the development of NSSI. In this study, we put forward three hypothesis: (1)PD would positively correlated with NSSI, (2)SI would mediate the relationship between PD and the frequency of NSSI and (3)the mediating effects exist/differ in sexes(male/female) and living areas(urban/rural).

Participants

A multi-center cross-sectional survey was conducted in 9 provinces of China from September to November 2020, and 435 DD adolescent outpatients were recruited from 20 psychiatric hospitals. After excluding 7 adolescents who did not complete the questionnaire, a total number of 428 participants were included in this study. Patients with cerebral trauma, epilepsy, schizophrenia, or other mental illness were excluded from this study. Inclusion criteria were 12–18 years old, met the diagnostic criteria for DD according to the Diagnostic and Statistical Manual of Mental Disorders(DSM-V), received education for more than 5 years. The participants were invited to fill out the self-report questionnaire.

Data collection

Demographic characteristics Self-reported questionnaire was utilized to investigate the main demographic characteristic of our participants, which recorded the age, sex(male/female), urbanicity(urban/rural), family annual income status(< 80000CNY, 80,000 ~ 200000CNY, ≧200,000CNY) of participants.

Suicidal ideation The first five items of the Beck Scale for Suicide Ideation(BSS) were used to evaluate SI³⁶. The scale asked the patients to respond to questions on items like “Wish to live”, “Wish to die”, “Reasons for living or dying”, “Active suicide attempts”, “Passive suicide attempts”. And the responses were three-point, from “No”, “Moderate”, to “Strongly”. All items were scored on a range from 0 to 2. The higher score indicated the more intense SI. The BSS a widely used suicide ideation scale with good reliability, the Cronbach's alpha coefficient was 0.841 in this study.

Psychological distress The Kessler Psychological Distress Scale(K-10) was used to evaluate PD, which has been widely used in Chinese populations^37,38. It consists of 10 questions asking about the frequency of non-specific PD in the past month. Each question has five answers, ranging from ‘none of the time’ to ‘all of the time’, and was scored from 1 to 5 correspondingly. All items were summed up to calculate the total score. In this study, internal consistency reliability was 0.882.

The frequency of NSSI We adopted the self-report scale, the Chinese version of Functional Assessment of Self-Mutilation (FASM)³⁹, to assess participants’ engagement of NSSI. The original FASM is constructed by Lloyd⁴⁰, contained items to investigate the frequency, kinds, and reasons for NSSI. In this study, we employed the NSSI checklist, which contains 10 different forms of NSSI procedures. Every item asked question about the NSSI frequency and whether they received medical treatment. For analysis convenience, we recode the frequency of NSSI into 5-point scale: 0 (0 times), 1(1 time), 2(2–5 times), 3(6–10 times), and4(> 11 times)^41,42.

Statistical analysis

The independent t test was used to examine the difference of continuous variables (i.e., PD score, SI score, perceived multidimensional social support, the frequency of NSSI) between different subgroups. The chi-square tests were utilized for category variable comparison. The factors that explain little or remained no significance would not be included in further analysis. The common methods variance were tested using Harman single-factor test methods⁴³, of which the BSS, K-10 were included in the analysis. To test the mediation effect of SI in the relationship between PD and NSSI, the mediation analysis was conducted⁴⁴. The bootstrap procedure was adopted to estimate the 95% bias-corrected confidence intervals(CI) around the indirect effects. When the estimation of 5000 samples and the 95%CI did not contain 0, the indirect effect was considered significant. The mediation effect of SI was tested in different sexes and living areas. All the analyses were performed on Statistical Package for the Social Sciences version 25.0(IBM), and the mediation analysis was conducted on PROCESS 3.2(Model 4).

Demographic characteristics and correlation analysis

Among 428 DD adolescents(mean age = 14.95, SD = 1.67), most of the participants are female adolescents, which accounts for 81.5%(349/428) of the participants. Approximately 69.6%(297/428) of the sample comes from urban areas. The great majority of households earn less than 200,000 yuan each year. Male adolescents in our study are older than female adolescents, and males come from wealthier families. Female adolescents seemed to encounter more serious PD. Additionally, the urban participants have higher households’ income than rural. Adolescents who lived in rural areas showed higher SI(All p value < 0.05) (See Table 1). The PD was significantly positively correlated with the SI, and frequency of NSSI(See Table 2).

Table 1

Main characteristics of 428 depressive adolescents with self-injury.
Variables	Total	Male adolescents	Female adolescents			Urban	Rural
Variables	(N = 428)	(N = 79)	(N = 349)	t/χ²	p value	(N = 298)	(N = 130)	t/χ²	p value
Age, year	14.95 ± 1.67	15.46 ± 1.57	14.84 ± 1.67	2.994	0.003**	14.86 ± 1.65	15.17 ± 1.69	-1.774	0.077
Live area
Urban	298(69.6%)	61(77.2%)	237(67.9%)	2.638	0.104	/	/	/	/
Rural	130(30.4%)	18(22.8%)	112(32.1%)			/	/	/	/
Income, yuan
< 80000	168(39.3%)	24(30.4%)	144(41.3%)	5.779	0.016**	99(33.2%)	69(53.1%)	21.821	< 0.001***
80000 ~ 200000	184(43%)	34(43.0%)	150(43.0%)			132(44.3%)	52(40.0%)
> 200000	76(17.8%)	21(26.6%)	55(15.8%)			67(22.5%)	9(6.9%)
K-10	36.90 ± 7.21	34.96 ± 7.34	37.34 ± 7.12	-2.670	0.008**	36.68 ± 7.52	37.41 ± 6.44	-0.954	0.341
Beck	6.27 ± 2.75	6.14 ± 2.69	6.30 ± 2.76	0.472	0.637	6.07 ± 2.76	6.72 ± 2.68	-2.261	0.024*
Frequency	15.61 ± 8.90	13.81 ± 9.49	16.02 ± 8.72	-1.898	0.060	15.49 ± 9.12	15.89 ± 8.40	-0.426	0.670
p < 0.05; p < 0.01; **p < 0.001.
Beck: Average score of Beck Suicide Ideation Scale;
K-10: Average score of Kessler Psychological Distress Scale;
Frequency: Average frequency of NSSI in depressive adolescents.

Table 2

Correlation among psychological distress, SI, and self-injury in depressive adolescents.
		K10	Beck	Frequency
Male adolescents
	K-10	1	0.373***	0.513***
	Beck		1	0.415***
	Frequency			1
Female adolescents
	K-10	1	0.521***	0.394***
	Beck		1	0.432***
	Frequency			1
Urban
	K-10	1	0.553***	0.433***
	Beck		1	0.466***
	Frequency			1
Rural
	K-10	1	0.320***	0.398***
	Beck		1	0.335***
	Frequency			1
Total
	K-10	1	0.492***	0.425***
	Beck		1	0.429***
	Frequency			1
p < 0.05; p < 0.01; **p < 0.001.
K-10: Average score of Kessler Psychological Distress Scale;
Beck: Average score of Beck Suicide Ideation Scale;
Frequency: Average frequency of NSSI in depressive adolescents.

Mediation analysis

All the tested variables were included in the exploratory factor analysis using the Harman single-factor test method. Factors with a latent root greater than 1 were obtained without rotation, as the variation explained by the first factor was 25.76%, which is lower than the critical standard of 40%. Thus, no common method variance existed in the research data, and these scales were able to conduct the mediation effects analysis. All models were shown in Table 3. The total effects of PD on the repeated NSSI, including direct effects and indirect effects, in the unadjusted model 1 indicated that the mediation effects account for 33.59% of the total effects on the total sample. Meanwhile, it accounts for 18.85% of male adolescents and is lower than it is in female adolescents(41.20%). As shown in model 2, after adjusting for urbanity status, and family household indirect effects took up 18.05% of the total effects in male adolescents, which were lower than in female adolescents(39.23%). According to model 3, after controlling the sex, and family household, the indirect effects account for 43.35% in urban participants, which were higher than that in rural participants(15.55%). After controlling sex, urbanity status, and family household, the indirect effect accounts for 45.08% of total effects, which is presented in model 4.

Table 3

Mediating effect of psychological distress between SI and self-injury.
				Direct effect		CI	Indirect effect	CI(bootstrap)		Mediation ration(%)
	model	a	b	c'	LLCI	ULCI	(a*b)	LLCI	ULCI	ab/(ab + c’)
Male adolescents	1	0.137***	0.916**	0.538**	0.275	0.8	0.125	0.015	0.269	18.85%
	2	0.139***	0.865**	0.543**	0.273	0.813	0.12	0.009	0.261	18.05%
Female adolescents	1	0.202***	0.985***	0.284***	0.15	0.417	0.199	0.133	0.273	41.20%
	2	0.181***	0.925***	0.260***	0.126	0.394	0.168	0.103	0.237	39.23%
Urban	1	0.203***	1.078***	0.307***	0.164	0.451	0.218	0.137	0.307	41.44%
	3	0.195***	1.037***	0.234***	0.119	0.409	0.202	0.125	0.287	43.35%
Rural	1	0.133***	0.726**	0.422***	0.207	0.637	0.097	0.026	0.189	18.60%
	3	0.113**	0.696**	0.428***	0.208	0.649	0.079	0.016	0.166	15.55%
Total	1	0.187***	0.940***	0.348***	0.23	0.465	0.176	0.118	0.239	33.59%
	4	0.172***	0.889***	0.324***	0.205	0.443	0.153	0.098	0.215	45.08%
p < 0.05; p < 0.01; **p < 0.001. a: Effect of psychological distress on SI.
b: Effect of SI on repeated self-injury.
Model 1: Single-factor analysis.
Model 2: Adjusted for urbanicity, family income.
Model 3: Adjusted for sex, family income.
Model 4: Adjusted for sex, urbanicity, family income.

Our study provided evidence for the mediating role of SI in the association between PD and the frequency of NSSI among Chinese adolescents with DD. Adolescents who experience more severe PD have more frequently NSSI, and this relationship was mediated by SI. Furthermore, we found the mediating effects were stronger in female adolescents than in male adolescents, and this mediating effect was stronger in rural adolescents than urban adolescents.

This study replicated that PD was positively correlated with the frequency of NSSI. PD is suggested as a predisposing factor of NSSI⁴⁵. and a large body of studies have highlighted that PD was positively correlated with the frequency of NSSI¹². A longitudinal study also observed a positive correlation between PD and NSSI⁴⁶. Alongside this, our evidence indicated that DD adolescents who experienced higher PD were vulnerable to arise in SI, which was in line with Chamberlain⁴⁷. The SI was found to be positively correlated with the frequency of NSSI in the current study, implying that the more people intend to commit suicide, the higher the frequency of NSSI being administered. Two opinions are widely used to explain the relation between SI and NSSI. Jonier et al. explained that people who want to commit suicide may increase their frequency of NSSI to acquire the capability of suicide¹, and some researchers hypothesized that NSSI may be used as a short-term anti-suicide method, representing a short-term compromise to avoid utter annihilation^23,48. Whether these adolescents engage in NSSI to get the ability to commit suicide or to avoid suicide is unclear, it is apparent that NSSI serves as a coping skill to SI. To probe the role of NSSI in handle with SI(prompt the suicide, or anti-suicide), further research to monitor the SI before and after NSSI is needed.

The tendency that female adolescents have higher PD than male adolescents were observed in the present study. It could be explained that there are different expectations for gender role in Chinese culture. Female adolescents are more likely to be neglected that their male counterparts. And male adolescents are expected to be more self-sufficient and independent, therefore, male adolescents have higher self-worth and lower PD⁴⁹. Subjective body image also contributed to these results female adolescents are more likely to rate their body image as “fat” “unhealthy” than males, and they are easily affected by their subjective perception of body image⁵⁰. It could potentially make female adolescents experience more PD than males. We found the SI and frequency of NSSI did not vary in different sexes. The current findings partly diverge from earlier studies that were conducted in high school and community students, implying that female adolescents have higher SI prevalence^27,51. This discrepancy could be explained by the fact that our study participants were depressed teenagers, as the sample characteristic was different from the school and community adolescents.

The mediating effects of SI between PD and NSSI were tested in different sexes. Whether controlling the urban-rural status or not, the mediating effects were stronger in female adolescents than it was seen in male adolescents. The result suggested that female adolescents with depression are more likely to arise in SI, which results in a higher frequency of NSSI. The possible explanation is the social and biological disparities between sexes. Previous research observed sex differences in coping with PD, the females were more prone to amplify their negative mood by ruminating and utilizing strategies involving emotional expression, while males were more likely to employ active coping strategies to reduce their depressive mood^52–54. This cognitive nature and cope difference could make females exposed to a greater risk of experiencing SI^55,56. Besides, the biological nature like menstrual cycle-related changes(ovarian hormone fluctuations) also increases the risk of SI^57–59. Furthermore, the different functions of NSSI(acquire the ability to suicide for female/emotion regulation for male) may contribute to the NSSI varies in sexes. Some studies have indicated that female depressed adolescents with NSSI are attempting to develop a habit of pain and the bravery to suicide^48,49,60,61, female inpatient adolescents may use NSSI to avoid suicide⁴⁸, while the male makes NSSI a nonproductive but efficient coping strategy for emotion regulation⁶². Therefore, longitudinal studies focus on the trajectories of NSSI and SI are required. For example, research on EMA methods, SI in adolescents before NSSI, during NSSI, and after NSSI is essential to clarify the function of NSSI and its disparities between sexes.

Identifying the urban-rural disparities of SI was essential for developing a targeted suicide prevention⁶³. In the current study, the rural adolescents have higher SI compared to their peers who lived in urban areas. Prior studies also found higher SI prevalence in people who lived in rural China^34,64. The possible explanation is that rural areas have more left-behind adolescents, who exhibited a higher tendency towards psychiatric disorder due to the parental absence and disrupt family structure^65,66. A lack of mental health services may also contribute to the higher SI in rural adolescents. Rural residents suffered from a shortage of professional mental health services were well documented^66,67. However, limited research investigated the disparities of mental health services utilization among adolescents in rural and urban China, and it remains unclear whether rural adolescents seek psychological treatment if they encounter SI.

The mediating effects of SI between PD and NSSI were examined in both urban and rural adolescents. According to the mediation analysis results, regardless of their sex in the analysis, however, compared to the rural DD adolescents, the urban DD adolescents were more prone to be affected by SI and later engage in frequent NSSI. This finding demonstrated that in urban depressed adolescents, the association between PD, SI, and the frequency of NSSI was stronger than in rural adolescents with depression. Combined with the higher suicidal ideation in rural adolescents, there was no significant difference in PD and NSSI between urban and rural adolescents. The current study implies except for PD, other factors may induce higher suicidal ideation(eg. the relation with caregiver) in rural adolescents. Thus, future studies on the differences between urban and rural teenagers in the development of suicidal thoughts are required. A previous study found people with SI had higher tendency to be exposed to information about NSSI via social networking sites⁶⁸. A tighter link between SI and frequency of NSSI in urban adolescents could be explained by disparities in Internet usage. According to the Research report on Internet Use of Minors in China, 2020, teenagers in cities use social networking sites more frequently than their peers in rural areas⁶⁹⁷⁰, which may lead to imitating and increasing the risk for NSSI. The tighter relation between SI and NSSI in urban adolescents results in a higher mediating rate of SI. No matter the urban adolescents want to acquire the ability to suicide or anti-suicide by frequently NSSI. More emphasis should be placed on urban depressed adolescents.

Our sample was drawn from hospitals in China that span about a third of the province and was representative of depressive adolescents in outpatient settings. Findings from the current study shed light on the rationale of repeated NSSI. It revealed that repeated NSSI may be driven from SI. It further reveals the intrinsic mechanism of PD and NSSI, which lies in the relationship among PD, NSSI, sexes, and urbanity. Our findings may provide novel insights to focus on the vulnerable adolescents in NSSI(e.g. living in urban, being female), and appropriate measures to help them reduce psychological pain and suicidal thoughts may help them reach a cessation of NSSI⁷¹. The result of our study may contribute to the scarce resources focused on reducing youth suicidal behaviors (e.g. SI, NSSI, suicide attempts) are deployed efficiently. Our study has limitations as well. The first one is that in this cross-sectional, retrospective with self-reported measurements, the temporal ordering was not definite. Thus, the interpretation of causal relationship is limited. Second, our participants were depressed adolescents admitted to the hospital, who may exhibit a greater rate of NSSI and more severe mental distress. It was unknown whether this effect would be generalized in the community or at school also. Third, as SI or NSSI was not accepted as social sanctions, participants may not report their real feelings, which may result in bias.

Among adolescents with depression, PD may influence NSSI behavior through SI. This mediating effect was significant stronger in female than in male adolescents, and rural residents. These findings may help to discover the mechanism of NSSI generation and therefore provide evidence for NSSI intervention and suicide prevention by reducing SI and PD.

Ethical Approval and Consent to participate

The design and data collection procedures were approved by the Ethics Committee of the institutional review Board(IRB) of the Shenzhen Kangning Hospital(protocol code: IRB:2020-K021-01). Informed consent was collected by all participants and their legal guardians.

Consent for publication

Not appliable.

Availability of supporting data

Data not available due to ethical restrictions.

Competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

This work was supported by Sanming Project of Medicine in Shenzhen (No.SZSM202011014), Shenzhen Fund for Guangdong Provincial High-level Clinical Key Specialties (No.SZGSP013), Shenzhen Key Medical Discipline Construction Fund (No.SZXK072), and Shenzhen Science and technology research and Development Fund for Sustainable development project (No.KCXFZ20201221173613036)

Authors' contributions
Ruifen Li: Writing- Original draft preparation, Methodology; Yanni Wang: Writing- Reviewing and Editing, Methodology; Lijuan Huo: Writing - Review & Editing, Methodology; Shiqi Lu: Review & Editing, Data curation; Jiayue Hao: Review & Editing, Data curation; Peng Li: Review & Editing, Data curation; Feng Zhu: Review & Editing, Investigation; Kongliang He: Review & Editing, Investigation; Tiansheng Zheng: Review & Editing, Investigation; Li Su: Supervision,Writing - Review & Editing, Conceptualization, Methodology; Yongjie Zhou: Supervision, Writing - Review & Editing, Conceptualization, Methodology, Funding acquisition

Acknowledgements

We apprecited for all the volunteers who participate our survey.

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Mediating effects of suicidal ideation in the relationship between psychological distress and non-suicidal self-injury among adolescents with major depressive disorder: The roles of sex and urban-rural status

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Abstract

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Introduction

The relationship of psychological distress to non-suicidal self-injury

Suicidal ideation as a mediator

The role of sex and urban

The current study

Methods

Participants

Data collection

Statistical analysis

Results

Demographic characteristics and correlation analysis

Mediation analysis

Discussions

Conclusions

Declarations

References

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