With rates of suicide ideation on the rise ²³ it is critical to identify factors associated with a greater risk of suicide ideation. Using the Interpersonal Theory as a framework, this study investigated whether factors related to perceived burdensomeness and thwarted belongingness were associated with suicidal ideation among a sample of Ontario adolescents enrolled in publicly funded schools. Consistent with our hypotheses, we determined that not knowing where to turn for support, feeling worthless, having low self-esteem, being bullied, and using cannabis were associated with greater odds of suicide ideation. While feeling hopeless, being cyberbullied, using alcohol and tobacco, and social media use were associated with greater odds of suicide ideation in the bivariate analyses, these variables were unexpectedly not associated with suicide ideation in the multivariate model.

The perceived burdensomeness indicators of low self-esteem and feelings of worthlessness had the strongest association with suicide ideation. This is consistent with research highlighting the association between low self-esteem and suicide attempts and ideation among adolescents, ²⁴ and supports the Interpersonal Theory in adolescents. One explanation is that self-esteem becomes more important as an individual enters adolescence because the self is perceived as more independent. ²⁴ Self-esteem is thought to remain stable throughout adolescence, so low self-esteem may be a stable problem that leads to emotional distress. ²⁴ Assessing self-esteem as part of suicide screening, and interventions aimed at improving self-esteem in adolescents may therefore be important parts of suicide prevention programs.

Consistent with previous research that found social support to prospectively protect against suicide attempts, ⁷ the thwarted belongingness indicator of perceived lack of availability of support, which represents the absence of reciprocally-caring relationships, was associated with increased odds of suicide ideation. This finding supports the Interpersonal Theory and suggests that mental health support for adolescents and awareness of how to access support are urgently needed. While persistent feelings of hopelessness were not associated with suicide ideation in the multivariate analysis, the Interpersonal Theory hypothesizes that hopelessness regarding the feelings of thwarted belongingness and perceived burdensomeness causes active suicidal desire, rather than hopelessness being an independent cause of suicidal ideation. ⁴ However, this finding is not in accordance with the literature on the association between hopelessness and suicide, possibly because of the additional variables included in our model. Beck et al. developed the Beck Hopelessness Scale and found hopelessness to be significantly related to suicidal ideation, ²⁵ and the Beck Hopelessness Scale has also shown predictive validity for suicide ideation in adolescents. ²⁶

While social media use was associated with suicide ideation at the bivariate level, after controlling for other factors in the multivariate model, social media use was not significantly associated with suicide ideation. The literature on the association between social media use and depression and suicide is conflicting. Some evidence suggests that social media may provide a sense of connectedness for adolescents and decrease feelings of loneliness, as higher levels of Facebook social connectedness were found to be related to lower levels of depression and anxiety ²⁷ and posting status updates on Facebook was found to decrease loneliness by feeling more connected with friends. ²⁸ Furthermore, social support and feelings of connectedness through social networks may be especially beneficial for those who have a harder time accessing support in person. ²⁷ However, other cross-sectional studies have found social media use to be associated with suicide attempts, ²⁹ and longitudinal studies are needed to better understand how social media use impacts suicidality in adolescents.

The finding that bullying is associated with suicide ideation is consistent with the literature on this topic ³⁰ and one study found that the association between bullying and suicide ideation in an adolescent sample was fully mediated by thwarted belongingness and perceived burdensomeness. ³¹ Shneidman's psychache theory of suicide proposes that suicide results when psychological pain, characterized by guilt, loneliness, and other negative feelings, becomes unbearable ⁴ and Bao, Li, Song, and Jiang similarly found that the association between bullying victimization and suicide ideation was fully mediated by psychological pain. ³² In the same study, family togetherness and peer support decreased the effect of psychological pain on suicide ideation. ³² Cyberbullying victimization is a known risk factor for suicide ideation ³³ but was not significantly associated with increased odds of suicide ideation in the multivariate model, possibly because the association is also mediated by the variables related to thwarted belongingness and perceived burdensomeness. Ameliorating feelings of psychological pain, thwarted belongingness, and perceived burdensomeness in bully victims may therefore offer a potential target for interventions, and increasing social support may be one method of reducing the effect of these feelings on the development of suicide ideation.

Substance use is another known risk factor that is associated with adolescent suicidal ideation.^34,35 The increased risk of suicide ideation in daily cannabis users has been shown to be partly due to higher levels of perceived burdensomeness and thwarted belongingness. ³⁶ This supports the idea that those who use substances may perceive themselves to be a burden on others and have a reduced sense of belonging which contributes to their suicidality. Biological theories of suicide propose that dysregulation of the serotonergic, noradrenergic, and dopaminergic neurotransmitter systems contribute to suicidal thoughts and behavior, ³⁷ and animal studies have found cannabis use in adolescence to produce dysfunction in each of these neurotransmitter systems. ³⁸ While alcohol use was not significantly associated with suicide ideation in the multivariate model, Lamis and Malone found that perceived burdensomeness and thwarted belongingness were mediators between alcohol-related problems and suicidal proneness in college students, ³⁹ which may account for the lack of a direct association between alcohol use and suicide ideation. Assessing substance use may therefore be another important aspect of suicide screening in adolescents, and adolescent cannabis users may be a specific group to target for suicide prevention programs.

There are several limitations of the study. First, the study is cross-sectional, so causality, temporality and directionality of associations cannot be inferred. The study was also limited to using a single item asking about suicide ideation and could not differentiate the severity of the ideation. Additionally, there were different time intervals for some of the variables, further limiting any inference of temporality or directionality. While the factors that were associated with suicide ideation were consistent with the Interpersonal Theory, it is not possible to determine whether these factors contributed to suicide ideation or occurred before an individual experienced suicide ideation. The study design and use of OSDUHS did, however, allow for a large sample size with relatively reliable data collection. Second, OSDUHS did not use the Interpersonal Needs Questionnaire to guide the selection of items included in the survey and the variables selected in this study are proxy measures for thwarted belongingness and perceived burdensomeness. However, the constructs of thwarted belongingness and perceived burdensomeness are general and the items in OSDUHS used in this study align with the items in the Interpersonal Needs Questionnaire. Third, the OSDUHS target population is adolescents enrolled in public schools and excluded groups include students who were homeschooled, institutionalized, and enrolled in private schools, schools in First Nations communities, or schools in the remote northern region of Ontario. Some of the excluded groups, such as those who are marginally housed, incarcerated, or in group homes, experience a greater burden of disease related to suicide and suicidality,^40,41 and the findings from the current study may not be generalizable to these groups. The target population is, however, representative of the vast majority of Ontario children and adolescents. ¹⁶ Additionally, the results are not generalizable to suicide attempts in adolescents as this study did not assess whether the factors associated with increased odds of suicide ideation were associated with suicidal attempts.