Youth Suicide Risk Factors and Attitudes in New York and Vienna: A Cross-Cultural Comparison

Suicide and Life-Threatening Behavior 36(5) October 2006  2006 The American Association of Suicidology

539

Youth Suicide Risk Factors and Attitudes in New York and Vienna: A Cross-Cultural Comparison Kanita Dervic, MD, Madelyn S. Gould, PhD, MPH, Gerhard Lenz, MD, Marjorie Kleinman, MS, Tuerkan Akkaya-Kalayci, MD, Drew Velting, PhD, Gernot Sonneck, MD, and Max H. Friedrich, MD

The prevalence of suicide risk factors and attitudes about suicide and helpseeking among New York and Viennese adolescents were compared in order to explore possible cross-cultural differences. Viennese adolescents exhibited higher rates of depressive symptomatology than their New York counterparts and had more first-hand experience with suicidal peers. More attribution of suicide to mental illness was reported in Vienna; yet Viennese youth were less likely than New York adolescents to recognize the seriousness of suicide threats. Help-seeking patterns of Viennese adolescents were influenced by their setting a high value on confidentiality. These cross-cultural differences may reflect the limited exposure of Austrian youth to school-based suicide prevention programs. The findings highlight the need of taking the sociocultural context into consideration in the planning of youth suicide prevention strategies.

Austria has a higher overall and youth suicide rate than the U.S. In 2002, the overall suicide rate in the U.S. was 10.9 per 100,000 (Centers for Disease Control [CDC], 2002), whereas for Austria it was 19.3 per 100,000 (WHO, 2002). Among U.S. 15–19-year-olds, the suicide rate was 7.4 per 100,000 (CDC, 2002)

in 2002, whereas Austria had a higher rate of 9.5 per 100,000 (Statistik Austria, 2002). The underlying reasons for this difference is not known. An examination of the cross-cultural differences in the prevalence of suicide risk factors such as depression, substance or alcohol abuse, serious suicidal ideation, and pre-

Kanita Dervic, Tuerkan Akkaya-Kalayci, and Max Friedrich are with the Department of Child and Adolescent Neuropsychiatry, University Hospital, Medical University of Vienna, Austria; Madelyn Gould, Marjorie Kleinman, and Drew Velting are with the Division of Child and Adolescent Psychiatry, College of Physicians and Surgeons, Columbia University, and New York State Psychiatric Institute; Gerhard Lenz is with the Department of Psychiatry, University Hospital, Medical University of Vienna; and Gernot Sonneck is with the Department of Medical Psychology, University Hospital, Medical University of Vienna. At the time of the work on this paper, Dr. Dervic was a postdoctoral research fellow at the Division of Child and Adolescent Psychiatry at Columbia University. The New York part of the study was supported by grants from the National Institute of Mental Health, R01MH52827. The Viennese part of the study was funded by a grant of the Medical Scientific Fund of the Mayor of Vienna (No. 2074/2001). Portions of this paper were presented at the 51th Annual Meeting of the American Psychiatric Association, New York, NY, May, 2004. The authors wish to acknowledge John Graham Thomas, BA, for his assistance with statistical analyses. Address correspondence to Kanita Dervic, MD, Department of Child and Adolescent Neuropsychiatry, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria; E-mail: kanita. [email protected]

540 vious suicide attempts might shed light on the differential suicide rates. Besides the main psychiatric risk factors for youth suicide such as depression and substance abuse (e.g., Brent et al., 1993; Marttunen, Hillevi, Henriksson, & Lonnqvist, 1991; Shaffer et al., 1996), attitudes toward suicide may vary cross-culturally, being shaped to some extent by the cultural context and norms established by society (Kocmur, 1996). Addressing these attitudes could be an important part of youth suicide prevention efforts (Gould et al., 2004), and be of public health interest. Indeed, modifying the environment is a WHO recommended suicide prevention strategy (Leenaars et al., 2000). This encompasses more than restricting the means of suicide. For example, one environmental approach involves recommendations for media reports (Gould, Jamieson, & Romer, 2003; Leenaars et al., 2000; Sonneck, Etzersdorfer, & Nagel-Kuess, 1994). Exploration and targeting of maladaptive suicide attitudes could also be viewed in this context, since the cultural context might also affect help-seeking behavior (Bughra & Bhui, 2000). A cross-cultural comparison of predominant attitudes toward suicide and help-seeking behavior could improve our understanding of the sociocultural aspects of suicidal phenomena, and add new information that might serve as a basis for each society’s prevention strategies targeting environmental risk factors. Unfortunately, cross-cultural studies of attitudes about suicide among the young population of high school students are rare. In Eskin’s (1995, 1999) comparisons of suicide attitudes of Swedish and Turkish high school students, Turkish adolescents showed less stigmatization of a suicidal peer and more interaction with him/her in everyday life than their Swedish counterparts (Eskin, 1995). Swedish high school students endorsed greater disapproval of a peer’s suicidal disclosure in comparison to their Turkish peers, who tended to take more responsibility for a suicidal close friend (Eskin, 1999). In the population of older youth (i.e., college and university students), there are several crosscultural comparisons of the U.S. and other

Youth Suicide Risk Factors countries. A comparison of attitudes of U.S. and Japanese medical students regarding suicide (Domino & Takahashi, 1991) showed that the Japanese students had a more prevalent attitude of considering suicide as a normal behavior than the U.S. medical students. A comparison of Canadian and U.S. college students (Domino & Leenaars, 1989) revealed greater acceptance of suicide among Canadian youth despite a similar sociocultural milieu in both countries. Furthermore, a comparison of suicide attitudes of U.S. and New Zealand college students (Domino, MacGregor, & Hannah, 1988–89) showed greater awareness of causality between mental illness and suicide in New Zealand than in the United States. Although these studies present useful information on suicide attitudes outside the U.S., the use of different methodologies across studies limit the comparison of their results. Etzerdorfer, Vijayakumar, Schony, Graugruber, and Sonneck (1998) compared suicide attitudes of medical students in Austria and India and found less emphasis on the role of mental illness in suicidal behavior in Austria. In the present study we examined the rates of youth suicide risks, prevalence of adolescents’ maladaptive or desirable attitudes toward suicide, and help-seeking patterns in high school students in New York and Vienna. In contrast to other cross-cultural studies on adolescent suicide attitudes, the present study controlled for potentially confounding underlying risk factors in its examination of sociocultural contextual differences in attitudes and help-seeking behavior. To our knowledge, this is the first study comparing high school students’ suicide risk factors and attitudes in the U.S. and a Central European country. The findings from the study may shed light on the crosscultural variation in suicide rates.

SUBJECTS AND METHODS

Subjects Two thousand, four hundred nineteen high school students in six high schools in

Dervic et al. Nassau, Suffolk, and Westchester counties in New York State (for details of this study, see Gould et al., 2004) were compared with 214 high school students in three high schools in Vienna. The assessments of the schools commenced in New York in the fall of 1998 and ended in the spring of 2001. In Vienna, the assessment of the schools was performed in the fall of 2001. The participation rate was 63.4% in New York and 82.4% in Vienna. Schools in New York had no completed suicide by a student within 4 years of the survey; in Vienna, one school had a completed suicide by a student within this period. No school in Vienna received any kind of previous education on suicide, whereas for New York schools no information on prior suicide education was available. While individuals’ socioeconomic status (SES) was not assessed, information on the percentage of students receiving free or reduced lunch, which ranged from 0% to 12.1%, was available for the New York sample. In Vienna, information from the Ministry of Education indicated that 4.1% of the student body in the high schools of the same type as those surveyed in the present study received student financial aid. Separate statistics for specific schools were not available. In both cities, the samples were comparable in terms of age and gender. Measures The assessment battery and procedures employed in the U.S. study (Gould et al., 2004) were applied in Vienna. A selfreport questionnaire, administered during one class period, assessed the major psychiatric risk factors for teen suicide: depression, substance and alcohol abuse, previous suicidal behavior and current suicidal thoughts, as well as demographic characteristics. The assessment’s time frame was the previous 4 weeks, including the day of survey. The survey was translated into German and backtranslated into English for the current study, with the exception of the depression assessment, which employed the standard German version of the Beck Depression Inventory (Hautzinger, Bailer, Worall, & Keller, 1994).

541 Depression. The Beck Depression Inventory (BDI, Beck & Steer, 1993; Hautzinger et al., 1994) was employed to assess adolescent depression. The German version BDI was reported to have good internal consistency and validity (Cronbach’s alpha = 0.88, the average item-total correlation was 0.47) (Hautzinger, 1991). A cutoff point of 16 was employed in the present study to dichotomize BDI scores. This cutoff has correctly classified 81% of adolescent psychiatric patients with major depressive disorder (Strober, Green, & Carlson, 1981), and has been recommended to detect possible depression in normal population (Beck & Steer, 1993). Substance Use/Abuse. The Drug Use Screening Inventory (DUSI, Tarter, 1990; Tarter & Hegedus, 1991; Tarter, Laird, Bukstein, & Kaminer, 1992) was designed as a screening instrument for alcohol and/or drug use and problems among teenagers, and has been used extensively in adolescent populations (e.g., Kirisci, Hsu, & Tarter, 1994; Kirisci, Mezzich, & Tarter, 1995; Tarter & Hegedus, 1991; Tarter, Kirisci, & Mezzich, 1997; Tarter et al., 1992; Tarter, Mezzich, Hsieh, & Parks, 1995; Tarter, Mezzich, Kirisci, & Kazynski, 1994). The internal consistency for German translation of DUSI was .76 (Cronbach’s alpha). The substance use subscale has been reported to be more useful than the overall problem score for discriminating substance abusers from nonsubstance abusers (Kirisci, Mezzich, & Tarter, 1995). A cutoff point of ≥5 was used to dichotomize scores based on the recommended cutoff points, which roughly corresponded to 10% of the sample (Kirisci et al., 1995; Tarter, personal communication, 1995). Suicidal Ideation and Behavior. Eight items assessed the range of suicidal ideation and six questions asked about suicide attempts in the past 4 weeks as well as prior to the past 4 weeks (for details see Gould et al., 2004). These items have demonstrated good construct validity (Gould et al., 1998; Shaffer et al., 2004). Ideation was considered serious if the thoughts were rated as occurring most days or every day, the respondent was still thinking about suicide on the day of the survey, had made a specific plan, responded af-

542

Youth Suicide Risk Factors

firmatively to “have you thought seriously about killing yourself?” or responded with either of the two most serious response options on the BDI suicide item: “I would like to kill myself” or “I would kill myself if I had the chance.” A student was categorized as currently having serious suicidal ideation/behavior if the student met criteria for serious ideation or had made an attempt (regardless of injury or medical attention) within the past 4 weeks of the survey. In the U.S., all these students, as well as those indicating any less serious suicidal ideation, were seen at the school by a project staff child psychiatrist, psychologist, or social worker to assess imminent risk of the suicidality expressed in the survey. In Vienna, all students providing a response indicating any concern about the survey or any medical problem, were offered an opportunity for assessment and treatment at the University Hospital for Child and Adolescent Neuropsychiatry in Vienna. Suicide Attitudes and Help-Seeking Behavior. Eighteen items inquired about knowledge and attitudes about suicide and helpseeking for a suicidal friend or for one’s own emotional distress. The attitude assessment scale was based on prior work by Shaffer et al. (1990; Shaffer, Garland, Vieland, Underwood, & Busner, 1991). Students were asked whether or not they agreed with ten statements, and in response to the question “What should you do if a friend tells you he/ she is thinking about killing himself/herself?” students were given eight yes/no response options. The items, as seen in Tables 1 and 2, have been shown to have adequate reliability and validity (Gould et al., 2004; Shaffer et al., 1991). Finally, to assess firsthand experience with a suicidal peer, students were asked whether anyone had ever told the student that he or she was thinking about killing him/herself. Procedure In both countries, a self-completion survey was administered in classroom settings suggested by the school administrator. The study procedures, consistent with the

Family Educational Rights and Privacy Act and the Protection of Pupil Rights Amendment, were approved by the Institutional Review Board of the New York State Psychiatric Institute/Columbia University Department of Psychiatry and by the Ethic Commission of Vienna Medical University. The New York procedures are described in detail in Gould et al. 2004, the procedure in Vienna was similar with the primary difference that the administration of the survey was performed anonymously. All students were offered an opportunity to contact the staff at the University Hospital in Vienna for any problems for which they were concerned. Analyses A series of chi-square analyses were first conducted to determine differences between the New York and Viennese samples on demographic factors and youth suicide risk factors, such as depression, substance problem, serious suicidal ideation, and previous first-hand experience with suicidal peer. A series of logistic regression analyses were conducted with each attitude as an outcome variable and city as the independent variable, controlling for any demographic factor or clinical risk factor that emerged as statistically significant in the first set of chi-square analyses. Furthermore, additional series of logistic regression analyses were performed to compare whether attitudes differed crossculturally for high risk youth (specifically depressed adolescents, adolescents with substance problem, serious suicidal ideators, and adolescents with first-hand experience with a suicidal peer [FHESP]) in both cities, controlling for ethnicity. Cross-cultural differences in attitudes were also examined within gender, employing conditional chi-square analyses. In order to investigate whether the relationship between confidentiality and helpseeking behavioral attitudes in New York and Vienna differed, a series of logistic regression analyses were conducted with each helpseeking behavior as a dependent variable and city (New York or Vienna), confidentiality (keep a secret or wouldn’t keep a secret), and

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543

TABLE 1

Suicide Attitudes and Knowledge about Suicide in New York and Viennese Adolescents Percentage of agreement with the following statements: Almost all kids who kill themselves are mentally ill. Any kid is capable of killing themselves if their problems get bad enough. Suicide as a possible solution to problems. Most kids who kill themselves are normal but they have had a lot of bad things happen to them. People should be able to handle their own problems without outside help. People who talk about suicide do not commit it. Drugs and alcohol are a good way to help someone stop feeling depressed. If you are depressed, it is a good idea to keep these feelings to yourself. Drugs and alcohol can cause depression to become so bad it can lead people to try to hurt or kill themselves. People who do risky things, like always driving very fast, may be trying to kill or hurt themselves, and could use some help.

New York (n = 2,419)

Vienna (n = 214)

Adjusted OR†

95% CI

16.6%

24.8%**

.58

.41 to .81

73.1% 12.8%

48.1%*** 19.6%*

3.4 .66

2.5 to 4.5 .44 to .99

60.5%

57.5%

1.1

.82 to 1.4

17.0% 27.5%

11.2%* 44.9%***

1.6 .46

1.0 to 2.6 .34 to .62

10.7%

10.7%

1.1

.71 to 1.8

7.6%

33.2%***

.15

.10 to .21

80.0%

75.7%

1.3

.96 to 1.9

36.8%

33.6%

1.1

.81 to 1.4

*p < 0.05; **p < 0.01; ***p ≤ 0.001 †controlled for ethnicity, depression, and first-hand experience with a suicidal peer.

the interaction term of city-by-confidentiality as the independent variables. The statistical analyses were conducted using SPSS statistical software, version 11.0 and SAS statistical software, version 8.

RESULTS

The samples in New York and Vienna were comparable in terms of gender (males: 58.3% vs. 54.7%, χ2 = 1.0, df = 1, p = .299,

TABLE 2

Adolescents’ Help-Seeking Behavior in New York and Vienna Percentage of agreement with the following statements: Tell my friend to see a mental health professional. Tell my friend to call a hotline. Tell my friend to talk to his/her parents. Talk to my friend without getting anyone else’s help. Talk to an adult about my friend. Get advice from another friend. I wouldn’t take it seriously. I would keep it a secret.

New York (n = 2,419)

Vienna (n = 214)

Adjusted OR†

95% CI

70.4% 44.2% 62.8% 24.0% 66.9% 39.0% 6.9% 7.7%

68.7% 26.2%*** 65.9% 50.5%*** 50.5%*** 49.5%*** 3.3% 82.7%***

1.1 2.2 .83 .32 1.9 .65 2.0 .01

.81 to 1.5 1.6 to 3.0 .60 to 1.1 .24 to .43 1.4 to 2.6 .49 to .87 .92 to 4.3 .009 to .02

*p < 0.05; **p < 0.01; ***p ≤ 0.001 †controlled for ethnicity, depression, and first-hand experience with a suicidal peer.

544

Youth Suicide Risk Factors

respectively), age (15.5 ± 1.3 vs. 15.4 ± 1.4, t = .788, df = 2620, p = .431, respectively), and household composition (living in an intact family) (73.1% vs. 70.9%, χ2 = .55, df = 1, p = .457, respectively); however, there were significantly more Whites in Vienna than in New York (95.8% vs. 77.7%, χ2 = 38.7, df = 1, p < .001). As for other ethnicities in New York and Vienna, African Americans were represented with 5.5% vs. 0%, Hispanic 7.4% vs. 0.5%, Asian 3.8% vs. 1.9%, and Others 5.7% vs. 1.9%, respectively. With regard to the risk factors, a higher prevalence of depression (14.5% vs. 9.7%, χ2 = 4.9, df = 1, p = .026) and first-hand experience with a suicidal peer (45.2% vs. 33.6%, χ2 = 11.6, df = 1, p = .001) were found in Vienna than in New York. Comparable prevalence rates for substance problems (9.7% vs. 8.4%, χ2 = .37, df = 1, p = .541), serious suicidal ideation (7.9% vs. 6.0%, χ2 = 1.2, df = 1, p = .267), and life-time suicide attempts (3.6% vs. 1.9%, χ2 = 1.7, df = 1, p = .185) in New York and Vienna were found. Adolescents’ Attitudes Toward Suicide The rates of endorsement of suicide attitudes among New York and Viennese adolescents are given in Table 1. Adolescents in Vienna were significantly more likely than their counterparts in New York to believe that children who commit suicide are mentally ill, and that not any youth is capable of killing him/herself. Students in Vienna were also more likely than those in New York to endorse the attitudes that, “if depressed it is good to keep feelings to oneself,” “people who talk about suicide do not commit it,” and “suicide is a possible solution to problems.” New York students were more likely to believe that people should handle their own problems without outside help. In both cities, adolescents recognized that drugs and alcohol problems were a risk for suicidal behavior. Help-Seeking Behavior While students in both cities were apt to suggest that a suicidal peer see a mental

health professional, and also advise a suicidal friend to talk to his/her parents (see Table 2), significantly more Viennese than New York students would keep a friend’s suicidal intentions a secret, would talk with a suicidal friend without getting anyone else’s help, or try to get advice from another friend. Students in Vienna were also less likely to talk with an adult about a friend’s suicidality than their peers in New York as well as less likely to suggest the use of hotline to a suicidal friend. The patterns of associations between confidentiality and the help-seeking attitudes were different in New York and Vienna (see Table 3). While in both cities youth who would keep secret a peer’s suicidal intentions were more likely to talk to a suicidal peer without getting anyone else’s help, there were significant differences in other helpseeking patterns. In Vienna, the youth who endorsed a greater importance to confidentiality (82.7%) were significantly more likely to recommend a suicidal peer to see mental health professional, call a hotline, to talk to parents, to talk to an adult, to seek advice among peers, and to take a friend’s suicidal expressions seriously. For New York adolescents, those who attached importance to keeping a peer’s suicidality confidential (7.7%) were significantly less likely to recommend that a suicidal peer see a mental health professional, call a hotline, talk to parents, talk to an adult, seek advice among peers, and to take a friend’s suicidal intentions seriously. Attitudes Toward Suicide in At-Risk Adolescents and with Regard to Gender Both boys and girls in Vienna were more likely than their counterparts in New York to endorse the attitudes “if depressed it is good to keep feelings to oneself” and “people who talk about suicide do not commit it” (see Table 4). Additionally, boys in Vienna were less likely than New York boys to think that kids who kill themselves are normal but had a lot of bad things happen to them, to recognize that drugs and alcohol can cause depression which could lead to suicidal be-

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545

TABLE 3

Comparison of Help-Seeking Behavior in Adolescents Who Would Keep Secret a Peer’s Suicidal Intentions with those Who Would Not in New York and Vienna New York

Vienna

Would keep Would keep secret Would not secret Would not Percentage of agreement with (n = 187; (n = 2,232; (n = 177; (n = 37; the following statements: 7.7%) 92.3%) 82.7%) 17.3%) Tell my friend to see a mental health professional. Tell my friend to call a hotline. Tell my friend to talk to his/ her parents. Talk to my friend without getting anyone else’s help. Talk to an adult about my friend. Get advice from another friend. I wouldn’t take it seriously.

OR (95%C.I.)†‡

55.1

71.7

70.6

59.5

3.4 (1.5–7.5)**

34.2

45.0

29.9

8.1

7.5 (2.1–26.8)**

44.4

64.4

72.3

35.1

10.5 (4.6–23.7)***

57.8

21.2

54.2

32.4

.46 (.20–1.05)

38.5

69.3

53.7

35.1

7.8 (3.5–17.4)***

43.9 23.5

38.6 5.5

54.2 1.7

27.0 10.8

2.6 (1.1–6.2)* .02 (.005–.12)***

*p < 0.05; **p < 0.01; ***p ≤ 0.001 †Separate logistic regressions for each help-seeking behavior as the dependent variable, and city, “would keep secret” and interaction term for city-by-“would keep secret” as independent variables. ‡Values represents OR and 95% C.I. for interaction city-by-“would keep secret”

havior, and to recognize the suicidal potential of risky behavior. Viennese girls were more prone than girls in New York to think that children who commit suicide are mentally ill, and that suicide might be a solution to problems. As for adolescents at risk, the depressed youth in New York and Vienna did not differ significantly on attitudes toward suicide, with the exception that depressed adolescents in Vienna were less likely to think that any teenager is capable of killing themselves if their problems get bad enough. The youth with a substance problem in Vienna were less likely to think that any teenager is capable of killing themselves and more likely to endorse the statement “if depressed it is good to keep feelings to oneself” than their counterparts in New York, but there were no other significant differences. Youth expressing serious suicidal ideation in Vienna were also more likely to think “any kid is capable of killing themselves” than youth with serious suicidal

ideation in New York. As for youth with FHESP, those in Vienna were less likely to think that any kid is capable of killing themselves, and more likely to endorse the statement that people who talk about suicide do not commit it, and “if depressed it is good to keep feelings to oneself” (see Table 4). Help-Seeking Behavior in At-Risk Adolescents and with Regard to Gender Both boys and girls in Vienna were less likely to recommend a suicidal peer to call a hotline, to talk to an adult about a suicidal peer, and more likely to talk alone to a suicidal peer and to keep secret the peer’s suicidal intentions (see Table 5). Additionally, Viennese girls were more likely than girls in New York to seek advice among peers. As for at-risk adolescents, the youth with depression, substance problems and serious suicidal ideation in Vienna were more likely to talk

Depression‡

Substance Problem‡ SSI‡

FHESP‡

25.6*

13.7

13.0

34.8

45.3**

31.0

66.7**

12.8**

21.8

77.5

50.4*

61.2

31.6***

44.4*** 17.3

73.8 13.5

9.3

24.8

20.2

39.5

83.5

5.2

7.3

22.5

10.2

59.6

72.0 11.8

11.6

43.4

86.6

35.1***

7.2

44.3***

9.3

66.0

52.6*** 22.5**

24.7***

36.6

75.0

27.6

22.4

33.2

29.3

67.7

84.9 41.4

11.6

51.6

74.2

38.7

19.4

41.9

22.6

71.0

64.5** 46.4

22.6

26.5

68.4

13.7

33.8

38.0

31.6

62.0

79.5 23.3

16.7

27.8

72.2

44.4***

33.3

38.9

22.2

50.0

55.6* 25.0

27.8

35.6

69.2

25.3

26.7

28.1

36.3

69.2

83.6 57.7

8.2

23.5

76.5

52.9*

35.3

23.5

35.3

64.7

70.6 57.1

23.5

35.2

80.8

11.1

14.3

31.8

19.9

64.6

79.4 20.4

13.8

35.8

77.9

35.8***

11.6

44.2*

11.6

66.3

56.8*** 24.2

21.1

New New New New New New York Vienna York Vienna York Vienna York Vienna York Vienna York Vienna n = 1,411 n = 117 n = 1,008 n = 97 n = 232 n = 31 n = 234 n = 18 n = 146 n = 17 n = 790 n = 95

Females

*p < 0.05; **p < 0.01; ***p ≤ 0.001 †chi-square analyses ‡logistic regressions within the respective subsample (i.e., depression, substance problem, SSI, FHESP) with suicide attitude as dependent variable and city as independent variable, controlling for ethnicity

Almost all kids who kill themselves are mentally ill. Any kid is capable of killing themselves if their problems get bad enough. Suicide as a possible solution to problems. Most kids who kill themselves are normal but they had a lot of bad things happen to them. People should be able to handle their own problems without outside help. People who talk about suicide do not commit it. Drugs and alcohol are a good way to help someone stop feeling depressed. If you are depressed, it is a good idea to keep these feelings to yourself. Drugs and alcohol can cause depression to become so bad it can lead people to try to hurt or kill themselves. People who do risky things, like always driving very fast, may be trying to kill or hurt themselves, and could use some help.

Percentage of agreement with the following statements:

Males

Gender†

A Comparison of Attitudes Toward Suicide in At-Risk Adolescents in New York and Vienna

TABLE 4

546 Youth Suicide Risk Factors

59% 23.9%** 67.5% 56.4%*** 46.2%*** 44.4% 6.0% 77.8%***

62.0 27.2 61.2 39.4 8.2 9.1

Vienna n = 117

65.8 38.5

New York n = 1,411

19.5 74.9 38.5 5.2 5.8

64.0

76.8 52.2

New York n = 1,008

43.3%*** 55.7%*** 55.7%*** 0.5%* 88.7%***

63.9%

80.4% 28.9%***

Vienna n = 97

Females

39.7 49.6 40.5 12.9 21.1

44.4

58.6 32.3

58.1* 54.8 54.8 3.2 93.5***

45.2

54.8 22.6

36.3 47.4 41.0 10.7 15.0

46.2

64.1 38.5

66.7%* 27.8% 50.0% 5.6% 83.3%***

50.0%

50.0% 33.3%

Vienna n = 18

Substance Problem‡

New New York Vienna York n = 232 n = 31 n = 234

Depression‡

39.7 44.5 43.2 12.3 25.3

40.4

54.8 28.8

New York n = 146

76.5%** 41.2% 64.7% 0 82.4%***

29.4%

35.3% 23.5%

Vienna n = 17

SSI‡

30.3 63.7 39.7 7.5 11.3

55.6

69.4 43.7

New York n = 790

65.3%*** 44.2%*** 49.5% 2.1% 88.4%***

66.3%

65.3% 25.3%***

Vienna n = 95

FHESP‡

*p < 0.05; **p < 0.01; ***p ≤ 0.001 †chi-square analyses ‡logistic regressions within the respective subsample (i.e., depression, substance problem, SSI, FHESP) with help-seeking modus as dependent variable and city as independent variable, controlling for ethnicity

Tell my friend to see a mental health professional. Tell my friend to call a hotline. Tell my friend to talk to his/her parents. Talk to my friend without getting anyone else’s help. Talk to an adult about my friend. Get advice from an another friend. I wouldn’t take it seriously. I would keep it a secret.

Percentage of agreement with the following statements:

Males

Gender†

A Comparison of Help-Seeking Behavior in At-Risk Adolescents in New York and Vienna

TABLE 5

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Youth Suicide Risk Factors

to a suicidal peer without outside help and to keep secret a peer’s suicidal intention than their New York counterparts, whereas they did not differ significantly on other attitudes (see Table 5). Among adolescents with FHESP, those in Vienna were less likely to recommend a suicidal peer to call a hotline and to talk to an adult, and more likely to talk alone with the suicidal peer and to keep secret their suicidal intentions than the New York youth with FHESP (see Table 5).

DISCUSSION

This study found significant crosscultural differences in the prevalence of suicide attitudes and risk factors between high school students in New York and Vienna. The prevalence of depressive symptomatology in Viennese adolescents, affecting almost one sixth of students in contrast to nearly one tenth of U.S. students, deserves attention as mood disorders represent the most common psychiatric risk factors for youth suicide (Brent et al., 1993; Marttunen et al., 1991; Shaffer et al., 1996). Since there are no previous reports on the prevalence of depression for Viennese adolescents, this current prevalence rate needs to be confirmed in future studies with larger sample sizes and more comprehensive psychiatric assessments. There are reports of the management of adult depression and suicidal risk by Viennese general practitioners (Ritter, Stompe, Voracek, & Etzersdorfer, 2002); unfortunately, there are no data for Viennese pediatricians regarding this issue. Additional training to raise the awareness of Viennese pediatricians about child and adolescent depression should be a priority of youth suicide prevention programs in Austria. There is a similar need in the U.S., as witnessed by the findings that in a study of 600 U.S. general practitioners and pediatricians (Rushton, Clark, & Freed, 2000), only 16% reported having no problems in early detection and treatment of depressed children and adolescents, and merely 8% of physicians reported that they received appro-

priate training for screening and treatment of depression in childhood and adolescence. Almost a half of Viennese adolescents reported first-hand experience with a suicidal peer, compared to a third of their New York peers, which is in accordance with the higher youth suicide rate in Austria. The high percentage of adolescents who were exposed to a suicidal peer in Vienna should be considered in the planning of youth suicide awareness school programs, as adolescents with previous experience with suicidal peers are prone to maladaptive coping strategies (Gould et al., 2004); fortunately, students with previous experience with a suicidal peer have been reported to be more receptive to information about suicide (Overholser, Hemstreet, Spirito, & Vyse, 1989). Attitudes and Knowledge About Suicide A greater awareness of the role of mental illness in adolescent suicidal behavior was shown by Viennese high school students in comparison to the New York youth. The percentage (almost a quarter) of Viennese youth who endorsed this was also greater than reports in other European countries, where only 10.8% of Turkish and 14.2% of Swedish high school students endorsed the same statement (Eskin, 1995). Of note, this finding in the Viennese high school population represents a more sound attitude than that found earlier by Etzersdorfer et al. (1998) in a study of Viennese medical students. Only 2% of Viennese medical students considered mental illness as a significant factor in someone’s suicide and 5% considered mental illness would be a factor in their own suicide. It is not clear whether the age difference (Viennese adolescents in the present study were on average 15 years old, and the medical students of the cited study performed in 1992 were on average 24 years old) or education through media in the recent years is responsible for this difference. The myth that people who talk about suicide do not commit it seems to be very prevalent. Almost a half of Viennese students and nearly one third of New York youth in

Dervic et al. the present study endorsed this attitude. This is consistent with previous cross-cultural reports: 49% of New Zealand’s (Domino et al., 1988–89) and 50% of Turkish undergraduate students (Lester & Icli, 1990) thought this myth to be true. Suicide expressions or threats are one of the warning signs of future suicidal behavior and are an important component in the estimation of suicide risk (Ringel, 1976; Sonneck, 2000). Ringel’s concept of “presuicidal syndrome” described suicidal threats as an indicator of seriousness of suicidal intentions, which has been empirically confirmed (Sonneck, 2000). Thus, the myth that talking about suicide is benign should be addressed through public health education about suicidal behavior for Viennese and New York youth. Although more prone to disclose depressed feelings to others than their Viennese counterparts, New York students were at the same time more likely (every sixth student) to endorse the attitude that people should handle their own problems without seeking outside help. To rely more on oneself could reflect greater individualism in American adolescents as reported in comparative studies (Chiou, 2001; French, Jansen, & Pidada, 2002). Nevertheless, there were relatively few adolescents (17% vs. 11%) in either country who would not rely on outside help in a difficult situation. Of interest, the attitudes toward suicide in at-risk adolescents in our study largely reflected the general attitudes in each society. More specific differences were found with regard to gender, where Viennese girls attached more importance to mental illness in suicidal behavior and were also more prone to think that suicide is a solution to problems than girls in New York. On the other hand, Viennese boys were less aware of the suicidal potential of alcohol, drugs, and risky behavior than their New York counterparts. Given that suicide is more common among adolescent males (Rutz & Wasserman, 2004) and the adolescent suicide rate among males is higher in Austria than in the U.S. (15.1 vs. 12.2 per 100.000, respectively) (Statistik Austria, 2002; CDC, 2002), this finding offers

549 useful information for existing youth suicide prevention programs in Austria. Help-Seeking Behavior for a Suicidal Friend In general, Viennese adolescents were more likely to take sole responsibility for a suicidal peer, talking alone with him/her or including other peers, and guaranteeing confidentiality. In contrast, the youth in New York preferred disclosure of a peer’s suicidal intentions, getting adults’ involved, and were less likely to handle the situation alone or to seek advise and help solely from peers. Similar to attitudes toward suicide, among at-risk adolescents and boys and girls in both cities help seeking resembled the predominant youth help-seeking patterns in each society. The differential correlates of confidentiality in Vienna and New York is an intriguing finding in this study. One might expect that the propensity to keep a suicidal friend’s intent a secret would be associated with other inadequate attitudes regarding help-seeking. Indeed, this was the case with the New York students in our study where keeping a friend’s suicidal intention a secret was significantly associated with other maladaptive help-seeking attitudes. Yet, surprisingly, the greater importance of confidentiality among Viennese youth was positively associated with active consideration of other help-seeking resources. It is possible that the same question is not understood in the same way in different cultures (Etzersdorfer et al., 1998). North American and Central European patterns of socialization are also different, and could explain some part of the behavioral differences. The importance which Viennese adolescents attach to confidentiality could explain their greater propensity to take responsibility and to mobilize further help for a suicidal peer in order to maintain the relationship. Alternatively, the U.S. school-based suicide prevention programs have been educating American students to disclose and communicate one’s own and peers’ suicidal intentions in order to get appropriate help. Programs providing knowledge about suicidality and help-seeking

550

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resources which consider specific features of the sociocultural context would be a valuable addition to youth suicide prevention strategies. Limitations This study has several limitations. One limitation was the employment of a convenience, rather than a random, sample of schools in both cities. The schools in New York, although socioeconomically diverse, were predominantly suburban and White so that the results cannot be generalized to an urban or more ethnically diverse setting. In Vienna, the schools were chosen with regard to diverse social background and a quality of student body. One school was a private (tuition fee) high school and two were public (no tuition fee) high schools. In terms of the school type, the surveyed schools included a business high school, a science high school,

and a grammar school. The technical high schools in Vienna where the student body might have generally lower SES were not included, so that the results cannot be generalized to these schools. Also, in one Viennese school (1/3 of the sample), there was one student suicide within the 4 years prior to our study which might have impacted the findings. The sample in Vienna was small, and thus findings need to be confirmed in future studies with a greater sample size. Next, the help-seeking attitudes largely reflected responses concerning encounters with a suicidal peer and not for the teenager’s own problems. Despite these limitations, the knowledge gained from this cross-cultural comparison offers valuable insights into what may be contributing to the differential attitudes regarding youth suicide and help-seeking behavior among Viennese and New York youth. This is the first such study of its kind among Viennese adolescents.

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Youth Suicide Risk Factors World Health Organization. (2002). http://www.who.int/mental_health/media/austria. pdf. Accessed: January 2005. Manuscript Received: April 9, 2005 Revision Accepted: December 30, 2005