Abstract

The aim of this study was to assess the presence of suicidal ideation and depressive symptoms among adolescents in Chiapas, Mexico based on predictor variables. A cross-sectional study adopting an ex post facto design was conducted with a non-probability sample of 4,759 students of both sexes with an average age of 18.4 years and using the following tools: the Center for Epidemiologic Studies Depression Scale, Roberts’ Suicidal Ideation Scale, the Impulsiveness Scale (IS), and the Rosenberg Self-Esteem Scale. The mean score obtained by the suicidal ideation scale was 0.2, which is lower than that reported by other studies, while the mean score for depressive symptoms was similar to those in the literature. The prevalence of suicidal ideation was 7.8%, which is lower than reported in national and international studies. Multivariable logistic regression showed that impulsiveness (OR = 1.907) and depressive symptoms (OR = 9.006) lead to a twofold and ninefold increase in the likelihood of suicidal ideation, respectively. The findings also showed a strong association between suicidal ideation and depressive symptoms, showing that the latter is a predictor of suicidal ideation among adolescents.

Key words
Suicidal ideation; Depressive symptoms; Adolescents

Introduction

There are 11.4 million young people aged between 18 and 24 years¹1. Instituto Nacional de Estadística y Geografía (INEGI). Panorámica de la población joven en México desde la perspectiva de su condición de actividad. México: INEGI; 2014. living in México, while in the State of Chiapas this number is approximately one million, 29% of whom are concentrated in five municipalities, including Tuxtla Gutiérrez²2. Instituto Nacional de Estadística, Geografía e Informática (INEGI). Información de México. Número de habitantes. México: INEGI; 2014..

Studies show high levels of vulnerability and susceptibility to mental health problems among this group related to risky sexual behaviors, drug use³3. Ballinas Y, Evangelista A, Nazar A, Salvatierra B. Condiciones sociales y comportamientos sexuales de jóvenes en Chiapas. Pap. Poblac. 2015; 21(83):253-286., depression and self-harm, the latter of which is one of the main causes of death among young people.⁴4. Instituto Nacional de Estadística y Geografía (INEGI). Estadísticas de mortalidad, 2011. Consulta interactiva de datos. México: INEGI; 2013.

The study of suicide, which is the second leading cause of mortality among the female population and the third among males aged between 10 and 24 years, is a complex and dynamic process⁵5. González C, Ramos L, Mariño M, Pérez E. Vidas en riesgo: Conducta suicida en adolescentes mexicanos. Acta Psiquiat Psicol Am Lat 2002; 48(1):74-84.. This problem accounts for 6% of deaths among this group and thus constitutes one of the most challenging public health problems⁶6. McKinnon B, Gariépy G, Sentenac M, Elgar FJ. Adolescent suicidal behaviours in 32 low- and middle-income countries. Bull World Health Organ 2016; 94(5) :340-350F.

7. Córdova M, Rosales P, Caballero R, Rosales J. Ideación suicida en jóvenes universitarios: su asociación con diversos aspectos psicosociodemográficos. Psicología Iberoamericana 2007; 15(2):17-21.^-88. Sánchez SJC, Villarreal GME, Musitu G, Martínez FB. Ideación suicida en adolescentes: un análisis psicosocial: Colegio Oficial de Psicólogos de Madrid, España. Psychosocial Intervention 2010; 19(3):279-287.. Suicidal ideation is one of the stages of this process and ranges from having thoughts about wanting to die to self-destructive fantasies and planning suicide⁹9. Goldney R, Winefield A, Tiggemann M, Winefield H, Smith S. Suicidal ideation in a young adult population. Acta Psychiatr Scand 1989; 79(5):481-489.. Mood disorders, impulsivity and despair are factors that influence planning, intention and carrying out a suicide attempt¹⁰10. Bebbington P, Minot S, Cooper C, Dennis M, Meltzer H, Jenkins R, Brugha T. Suicidal ideation, self harm and attempted suicide. Results from the British Psychiatric Morbidity Survey 2000. Eur Psychiatry 2010; 25(7):427-431.^,1111. Gradus JL, Qin P, Lincoln AK, Millar M, Lawler E, Lash TL. The association between adjustment disorder diagnosed at psychiatric treatment facilities and completed suicide. Clin Epidemiol 2010; 2:23-28..

A study conducted by Nock et al.¹²12. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, Chiu WT, Girolamo G, Gluzman S, de Graaf R, Gureje O, Haro JM, Huang Y, Karam E, Kessler RC, Lepine JP, Levinson D, Medina-Mora ME, Ono Y, Posada-Villa J, Williams DR. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry 2008; 192(2):98-105. with adults from 17 countries from five continents showed that the prevalence of suicidal ideation was 9.2%, while a study by Page et al.¹³13. Page RM, Saumweber J, Hall PC, Crookston BT, West JH. Multi-country, cross-national comparison of youth suicide ideation: Findings from global school-based health surveys. School Psychology International 2013; 34(5):540-555. using information from 266,694 students aged between 13 and 15 years from 49 countries calculated that prevalence was 15.3%. Another study undertaken by McKinnon et al.⁶6. McKinnon B, Gariépy G, Sentenac M, Elgar FJ. Adolescent suicidal behaviours in 32 low- and middle-income countries. Bull World Health Organ 2016; 94(5) :340-350F. with 164,770 adolescents from 32 countries reported a prevalence rate of 16.2% and 12.2% for men and women, respectively, showing that the gender difference was more accentuated in the Americas (20.1% and 11.4%) and that African countries showed the highest prevalence of suicidal ideation (22.5% and 20.1%, respectively). Other studies conducted with adolescents have shown similar prevalence rates to those reported above¹⁴14. Souza LDM, Silva RA, Jansen K, Kuhn RP, Horta BL, Pinheiro RT. Suicidal ideation in adolescents aged 11 to 15 years: prevalence and associated factors. Rev Bras Psiq 2010; 32(1):37-41.

15. Glashouwer KA, De Jong PJ, Penninx BWJH, Kerkhof AJFM, Van Dyck R, Ormel J. Do automatic self-associations relate to suicidal ideation? Journal of Psychopathology and Behavioral Assessment 2010; 32(3):428-437.

16. Kaess M, Parzer P, Haffner J, Steen R, Roos J, Klett M, Brunner R, Resch F. Explaining gender differences in non-fatal suicidal behaviour among adolescents: a population-based study. BMC Public Health 2011; 11:597.

17. Medina OC, Jegannathan B, Dahlblom K, Kullgren G. Suicidal expressions among young people in Nicaragua and Cambodia: a cross-cultural study. BMC Psychiatr 2012; 12(28):1-7.

18. Zhao J, Yang X, Xiao R, Zhang X, Aguilera D, Zhao J. Belief system, meaningfulness, and psychopathology associated with suicidality among Chinese college students a cross-sectional survey. BMC Public Health 2012; 12:668.

19. Nguyen DT, Dedding C, Pham TT, Wright P, Bunders J. Depression, anxiety, and suicidal ideation among Vietnamese secondary school students and proposed solutions: a cross-sectional study. BMC Public Health 2013; 13(1):1-10.^-2020. Shilubane HN, Ruiter RAC, van den Borne B, Sewpaul R, Reddy J, Reddy P. Suicide and related health risk behaviours among school learners in South Africa: Results from the 2002 and 2008 national Youth Risk Behaviour Surveys. BMC Public Health 2013; 13:926..

In Mexico, a study conducted by Pérez Amezcua et al.²¹21. Pérez-Amezcua B, Rivera-Rivera L, Atienzo EE, De Castro F, Leyva-López A, Chávez-Ayala R. Prevalencia y factores asociados a la ideación e intento suicida en adolescentes de educación media superior de la República mexicana. Salud Publica Mex 2010; 52(4):324-333. using data from a national sample from 2007 involving 12,424 adolescents reported that 47% of adolescents showed at least one symptom of suicidal ideation, while a recent study conducted with 2,386 high school students in the State of Campeche reported a prevalence rate of 13.1%²²22. González C, Juárez C E, Montejo L, Oseguera G, Wagner, Jiménez A. Ideación suicida y su asociación con drogas, depresión e impulsividad en una muestra representativa de estudiantes de secundaria del estado de Campeche, México. Acta Universitaria, Multidisciplinary Scientific Journal 2015; 25(NE-2):29-34.. Finally, a study developed by Hidalgo-Rasmussen & Hidalgo-San Martín²³23. Hidalgo-Rasmussen C, Hidalgo-San Martín A. Comportamientos de riesgo de suicidio y calidad de vida, por género, en adolescentes mexicanos, estudiantes de preparatoria. Cien Saude Colet 2015; 20(11):3437-3445. with 899 students aged between 14 and 18 years from urban and rural areas in the State of Jalisco, showed a prevalence rate of 8% among women and 4.5% in men. The differences in rates obtained by the above studies may be due to the use of different assessment tools and methods and differences in sample characteristics relating to geographical location (urban/rural) and age.

Depressive symptoms can lead to increased vulnerability of adolescents to conduct disorder, social isolation, substance use, and suicidal ideation⁸8. Sánchez SJC, Villarreal GME, Musitu G, Martínez FB. Ideación suicida en adolescentes: un análisis psicosocial: Colegio Oficial de Psicólogos de Madrid, España. Psychosocial Intervention 2010; 19(3):279-287.^,2424. Butcher JA, Mineka S, Holley JM. Psicología clínica. 12ª ed. Madrid: Pearson, Addison Wesley; 2007.

25. Bonanno R, Hymel S. Beyond hurt feelings: investigating why some victims of bullying are at greater risk for suicidal ideation. Merril Palmer Quarterly 2010; 56(3):420-440.^-2626. González C, Solís Torres C, Jiménez A, Hernández I, González A, Juárez F, Medina M, Fernández H. Confiabilidad y validez de la escala de depresión CES-D en un censo de estudiantes de nivel medio superior y superior, en la Ciudad de México. Salud Mental 2011; 34:53-59.. Symptoms include low mood, lack of appetite, irritability and motor restlessness. The prevalence of these symptoms among adolescents has been shown to range between 10 and 16% and tends to be higher among women²⁷27. González C, Hermosillo A, Vacio M, Peralta R, Wagner F. Depresión en adolescentes. Un problema oculto para la salud pública y la práctica clínica. Bol Med Hosp Infant Mex 2015; 72(2):149-155..

Impulsiveness is also considered to be a risk factor for suicidal ideation. It includes conduct that may place the well-being of both the person experiencing the behavior and others at risk, since it comprises a tendency to act without consideration of the consequences. This condition, together with other factors, lead to a fourfold increase in the likelihood of suicidal ideation²²22. González C, Juárez C E, Montejo L, Oseguera G, Wagner, Jiménez A. Ideación suicida y su asociación con drogas, depresión e impulsividad en una muestra representativa de estudiantes de secundaria del estado de Campeche, México. Acta Universitaria, Multidisciplinary Scientific Journal 2015; 25(NE-2):29-34.^,2828. González C, Ramos L, Caballero M, Wagner F. Correlatos psicosociales de depresión, ideación e intento suicida en adolescentes mexicanos. Psicothema 2003; 15(4):524-532..

One of the protective factors for psychosocial problems – which include suicidal ideation –, and a strong predictor of general well-being and emotional stability among adolescents, is self-esteem, whereby a person has a positive attitude towards him/herself and a sense of one's own value²²22. González C, Juárez C E, Montejo L, Oseguera G, Wagner, Jiménez A. Ideación suicida y su asociación con drogas, depresión e impulsividad en una muestra representativa de estudiantes de secundaria del estado de Campeche, México. Acta Universitaria, Multidisciplinary Scientific Journal 2015; 25(NE-2):29-34.^,2929. Jiménez A, Mondragón L, González FC. Self-esteem, depressive symptoms, and suicidal ideation in adolescents: Results of three studies. Salud Mental 2007; 30(5):20-26.^,3030. Miranda T, Cubillas R, Román P, Abril V. Ideación suicida en población escolarizada infantil: factores psicológicos asociados. Revista Salud Mental 2009; 32(6):495-502.. As such, high self-esteem is associated with low risk of suicidal ideation³¹31. Groot M, Kollen B. Course of bereavement over 8-10 years in first degree relatives and spouses of people who committed suicide: longitudinal community based cohort study. BMJ 2013; 347:f5519..

Although a number of studies have explored aspects related to risky sexual behavior and drug use, the literature on other psychosocial problems and mental health, which are particularly relevant given not only their increase and severity, but also their close relationship with the above problems, is scarce. It is therefore necessary to gain a deeper understanding of these aspects in order to inform the development of effective prevention and health promotion efforts.

This study therefore assesses the presence of suicidal ideation among adolescents from Chiapas, México based on predictor variables such as depressive symptoms, impulsivity and self-esteem.

Method and subjects

A cross-sectional study adopting an ex post facto nonexperimental design was conducted using a non-probability sample of 4,759 third-year preparatory school students from Chiapas, Mexico seeking admission to higher education courses offered by the Faculty of Humanities and Social Sciences and the Faculty of Nutrition and Food Sciences, both belonging to the University of Sciences and Arts of Chiapas, México, during the period 2011 to 2015.

The sample was made up of 3,275 women (68.8%) and 1,484 men (31.2%), with an average age of 18.4 years and standard deviation of 1.67 years.

Data collection techniques and tools

Standardized tools validated for use with the Mexican population were used. A pilot study was conducted to test the appropriateness of these tools, proving their semantic adequacy and that they were easily understandable.

The following tools were used:

• The Center for Epidemiologic Studies Depression Scale (CES-D)³²32. Radloff L. The CES-D scale: A self-report depression scale for research in the general population. Applied Psychol Meas 1977; 1(3):385-401., consisting of 20 items designed to measure depressive symptoms during the week prior to its application using a four-point scale with the following options: 0 = 0, 1-2 days = 1, 3-4 days = 2, and 5-7 days = 3. Overall score therefore ranges between 0 and 60. Internal consistency (≥ 0.83) and various types of validity have been shown to be consistently satisfactory by different studies with adolescents attending schools in rural³³33. Aguilera RM, Carreño MS, Juárez F. Características psicométricas de la CES-D en una muestra de adolescentes rurales mexicanos de zonas con alta tradición migratoria. Salud Mental 2004; 27(6):57-66. and urban²⁶26. González C, Solís Torres C, Jiménez A, Hernández I, González A, Juárez F, Medina M, Fernández H. Confiabilidad y validez de la escala de depresión CES-D en un censo de estudiantes de nivel medio superior y superior, en la Ciudad de México. Salud Mental 2011; 34:53-59.^,2828. González C, Ramos L, Caballero M, Wagner F. Correlatos psicosociales de depresión, ideación e intento suicida en adolescentes mexicanos. Psicothema 2003; 15(4):524-532. areas in Mexico.

• Roberts’ Suicidal Ideation Scale (SIS)³⁴34. Roberts E, Chen YW. Depressive symptoms and suicidal ideation among Mexican origin and Anglo adolescents. J Am Acad Child Adolesc Psychiatry 1995, 34(1):81-90., consisting of four items (three from the Roberts’ scale and one from the CES-D - I could not get “going”) regarding thoughts about death and taking one's own life over the previous seven days and also using a four-point scale with the following options: 0 = 0, 1-2 days = 1, 3-4 days = 2, and 5-7 days = 3. Overall score therefore ranges between 0 and 12. The scale has been shown to have satisfactory internal consistency using Cronbach's alpha (≥.80) and good construct validity²⁸28. González C, Ramos L, Caballero M, Wagner F. Correlatos psicosociales de depresión, ideación e intento suicida en adolescentes mexicanos. Psicothema 2003; 15(4):524-532.^,3535. González C, Ramos L, Vignau L, Ramírez C. Abuso sexual e intento suicida: Asociación con el malestar depresivo y la ideación suicida actuales en adolescentes. Salud Mental 2001; 24(6):16-25..

• The Impulsiveness Scale (IS)²⁸28. González C, Ramos L, Caballero M, Wagner F. Correlatos psicosociales de depresión, ideación e intento suicida en adolescentes mexicanos. Psicothema 2003; 15(4):524-532., consisting of five items with a four-point Likert scale with the following options: 1 = rarely, 2 = sometimes, 3 = often, and 4 = very often, used to assess the frequency of actions taken on impulse and lack of reflection on the consequences. This tool was validated for use with the Mexican population by González et al.³⁶36. González C, Andrade P, Jiménez J. Estresores cotidianos familiares, sintomatología depresiva e ideación suicida en adolescentes mexicanos. Acta Psiquiátrica Psicológica América Latina 1997; 43(4):319-326..

• The Rosenberg Self-Esteem Scale (RSS)³⁷37. Rosenberg M. Society and the adolescent self-image. Princeton: Princeton University Press; 1965., consisting of five positively worded items and five negatively worded items with the following options: 1 = Strongly agree, 2 = Agree, 3 = Disagree, and 4 = Strongly disagree. After reverse scoring the negatively worded items, the overall score ranges between 10 and 40, whereby the higher the score, the higher the self-esteem. Studies have shown that this tool has satisfactory internal consistency for use with Mexican adolescents (> .74)²⁹29. Jiménez A, Mondragón L, González FC. Self-esteem, depressive symptoms, and suicidal ideation in adolescents: Results of three studies. Salud Mental 2007; 30(5):20-26..

Procedure

The project was scientifically assessed by and received ethical approval from the Directorate of Research and Post-graduation at the University of Sciences and Arts of Chiapas.

Informed consent was obtained from the participants, who were informed that their responses would be kept confidential and anonymous. Those who accepted to participate voluntarily in the study authorized the use of information for research purposes. The information was protected in accordance with the principles and requirements laid out in the Declaration of Helsinki.

The scales were conducted by qualified psychologists according to standardized procedures and their application was supervised by a suitably qualified support team.

The overall scores obtained by each participant for each of the four scales were calculated based on the sum of each individual item score. Participants were then categorized according to cut-off scores, based on the mean score plus one standard deviation, resulting in the following scores: SIS = 1.0 (M = 0.2, SD = 0.8); CES-D = 16 (M = 10.3, SD = 5.9); IS = 11 (M = 8.2, SD = 2.4); and RSS = 23 (M = 28.5, SD = 6.4), considering a reference value for the latter scale of the mean minus the standard deviation to indicate normal and high level of self-esteem.

Based on these cut-off values, the predictor variables were categorized in binary form as follows:

• Suicidal ideation (0 - without ideation; 1 - presence of ideation).

• Depressive symptoms (0 - without depressive symptoms; 1 - with depressive symptoms).

• Impulsiveness (0 – low; 1 - normal).

• Self-esteem (0 – low; 1 - normal or high).

To assess the effect of the variables of interest on the likelihood of suicidal ideation, multiple logistic regression was performed using the categorical variables impulsiveness, self-esteem and depressive symptoms. The model was also run incorporating the adjustable variables age and sex. Based upon the results of this process, probability of extreme events were calculated.

Results

The large majority of participants (93.3%) studied in state education institutions, while the rest studied in private institutions. The grade point average in the last year was 8.26, with a standard deviation of .72. A little over half (50.5%) of the participants were from the state capital, Tuxtla Gutiérrez, while the rest were from other towns and areas in the state or from neighboring states such as Oaxaca, Veracruz, Tabasco and Puebla.

The results show that a little over half of the participants (2,437 or 51.2%) had experienced at least one of the problems under study: 369 cases (7.3%) showed evidence of suicidal ideation; 633 (13.3%) a high level of depressive symptoms; 2,020 (42.4%) low self-esteem; and 262 (5.5%) high levels of impulsiveness. The problem with the highest prevalence rate was low self-esteem.

The number of participants that showed evidence of suicidal ideation, depressive symptoms, low self-esteem, and high levels of impulsiveness was 21, revealing a very high level of psychosocial risk; while the number of cases who experienced the same problems, but with a low level of impulsiveness, was 107. The total number of participants who experienced all problems, with or without impulsiveness, was 128, which is equivalent to 2.68% of the total sample.

A preliminary regression analysis was performed to determine the association between the categorical variables and adjustable variables (age and sex) and to estimate their effect on the likelihood of suicidal ideation. The results for the adjustable variables were not significant, showing an odds ratio (OR) of close to 1, which is consistent with the findings of other studies³⁸38. Swahn MH, Palmier JB, Braunstein SM. Prevalence and Gender Differences in Suicide Ideation of Youth: A Cross-national Comparison of 19 Countries and Cities. International Household Survey Network 2012.. The lack of association between age and sex and suicidal ideation was confirmed using Student's t-test and chi-square test²2. Instituto Nacional de Estadística, Geografía e Informática (INEGI). Información de México. Número de habitantes. México: INEGI; 2014., respectively. With respect to gender, this result may be explained by development and improvements in socioeconomic status and working conditions among women over recent years³⁹39. Xu H, Zhang W, Wang X, Yuan J, Tang X, Yin Y, Zhang S, Zhou H, Qu Z, Tian D. Prevalence and influence factors of suicidal ideation among females and males in Northwestern urban China: a population based epidemiological study. BMC Public Health 2015; 15:961., particularly among the population group under question, while the age proximity of participants may explain the lack of significance. An analysis was therefore performed to predict the likelihood of suicidal ideation (SI) based solely on the significant variables self-esteem (SE), impulsiveness(IM), and depressive symptoms (DS).

The logistic regression results are shown in Table 1.

This implies that the LOGIT transformation can be expressed as follows:

The significance test for the generalized model obtained a p-value of ≤ .000, indicating that the model was significant. The significance value for each of the predictor variables SE, IM and DS was less than .05, showing that they were relevant. It is interesting to note from the results that normal/high levels of SE inhibit the likelihood of SI, while, conversely, high levels of IM and DS increase the likelihood. The ORs obtained therefore suggest that high levels of IM result in a twofold increase (OR = 1.907) in the likelihood of SI. Without doubt, however, the result that stands out most is the fact that the presence of DS leads to a ninefold increase in the likelihood of SI (OR = 9.006), corroborating the theory that high levels of depression are conducive to suicidal ideation and, ultimately, attempted suicide.

The results of the analysis of probability of extreme events are shown in Table 2.

The critical probability of SI without normal or high levels of SE, but with high levels of IM and the presence of DS, is close to .500. In contrast, when there are low levels of SE and low levels of IM and absence of SD, the likelihood of suicidal ideation is practically zero. In the context of the present study, the importance of the model lies in the fact that it allows the rapid assessment of warning signs of suicidal ideation in the population in question in cases of high levels of impulsiveness, low self-esteem and depression, all of which warrant intervention.

Discussion and conclusions

The nature of the data obtained by the present study allows for comparison with similar studies. With respect to measures of central tendency, the CES-D obtained a mean score of 10.3, which is similar to that reported by González et al.⁴⁰40. González GA, Juárez GF, Solís TC, González FC, Jiménez TA, Medina MME, Fernández VMH. Depresión y consumo de alcohol y tabaco en estudiantes de bachillerato y licenciatura. Salud Mental 2012; 35(1):51-55. in a study of preparatory school students in Mexico City (M = 9.5) and lower than that documented by Veytia et al.⁴¹41. Veytia LM, González ALFNI, Andrade PP, Oudhof H. Depresión en adolescentes: El papel de los sucesos vitales estresantes. Salud Mental 2012; 35(1):37-43. in a study undertaken with adolescents aged between 15 and 19 years in the State of Mexico (M = 16.2 for women and M = 16.02 for men).

The mean score obtained by the suicidal ideation scale was 0.2, which is much lower than the scores reported by other studies conducted in different states⁴²42. González C, Jiménez A, Mondragón L. Self-esteem, depressive symptomatology, and suicidal ideation in adolescents: results of three studies. Autoestima, sintomatología depresiva e ideación suicida en adolescentes. Revista Salud Mental 2007; 30(5):20-26.

43. Rosales JC, Córdova M, Villafaña A. Presencia de ideación suicida y su asociación con variables de identificación personal en estudiantes mexicanos. Acta Psiquiátrica y Psicológica de América Latina 2011; 57(2):91-98.^-4444. Rosales PJC, Córdova OM, Ramos CR. Ideación suicida en estudiantes mexicanos: un modelo de relación múltiple con variables de identificación personal. Psicología y Salud 2012; 22(1):63-74.. This may be due to a number of factors, including the influence of the religious prohibition of suicide and suicidal ideation⁴⁵45. Zarrouq B, Bendaou B, Elkinany S, Rammouz I, Aalouane R, Lyoussi B, Khelafa S, Bout A, Berhili N, Hlal H, Nejjari C, El Rhazi K. Suicidal behaviors among Moroccan school students: prevalence and association with socio-demographic characteristics and psychoactive substances use: a crosssectional study. BMC Psychiatry 2015; 15:284., cultural and economic diversity⁴⁶46. McKinnon B, Gariépy G, Sentenac M, Elgar FJ. Adolescent suicidal behaviours in 32 low- and middle-income countries Bulletin of the World Health Organization 2016; 94(5):340-350., and whether people admit to feeling the symptoms⁴⁷47. Weissman MM, Bland RC, Canino GJ, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Rubio-Stipec M, Wells JE, Wickramaratne PJ, Wittchen HU, Yeh EK. Prevalence of suicide ideation and suicide attempts in nine countries. Psychol Med 1999; 29(1):9-17..

The impulsiveness and self-esteem scales obtained mean scores of 8.2 and 28.5, respectively, which are similar to those reported by other studies⁴²42. González C, Jiménez A, Mondragón L. Self-esteem, depressive symptomatology, and suicidal ideation in adolescents: results of three studies. Autoestima, sintomatología depresiva e ideación suicida en adolescentes. Revista Salud Mental 2007; 30(5):20-26., though lower than those found by González & Landero⁴⁸48. González RMT, Landero HR. Escala de cansancio emocional (ECE) para estudiantes universitarios: Propiedades psicométricas en una muestra de México. Anales de Psicología 2007; 23(2):253-257. (M = 35.02).

Our findings also show that 7.8% of the participants were shown to have at least one of the symptoms of suicidal ideation, which is lower than the rates reported by international¹³13. Page RM, Saumweber J, Hall PC, Crookston BT, West JH. Multi-country, cross-national comparison of youth suicide ideation: Findings from global school-based health surveys. School Psychology International 2013; 34(5):540-555. and national²²22. González C, Juárez C E, Montejo L, Oseguera G, Wagner, Jiménez A. Ideación suicida y su asociación con drogas, depresión e impulsividad en una muestra representativa de estudiantes de secundaria del estado de Campeche, México. Acta Universitaria, Multidisciplinary Scientific Journal 2015; 25(NE-2):29-34. studies, in which prevalence rates ranged between 15.3 and 13.1%. Furthermore, 13.3% of the participants of the present study showed signs of depressive symptoms, which is similar to the levels reported by other studies²⁷27. González C, Hermosillo A, Vacio M, Peralta R, Wagner F. Depresión en adolescentes. Un problema oculto para la salud pública y la práctica clínica. Bol Med Hosp Infant Mex 2015; 72(2):149-155.

The logistic regression results show that impulsiveness and depressive symptoms lead to a twofold and ninefold increase in the likelihood of suicidal ideation, respectively, while self-esteem was shown to be a protective factor against suicidal ideation and depressive symptoms. These findings are in line with other investigations, including a study undertaken with schoolchildren aged between 12 and 16 years in the United Kingdon⁴⁹49. Sullivan SA, Lewis G, Gunnell D, Cannon M, Mars B, Zammit S. The longitudinal association between psychotic experiences, depression and suicidal behaviour in a population sample of adolescents. Soc Psychiatr Epidemiol 2015; 50(12):1809-1817. and another conducted by Souza et al.¹⁴14. Souza LDM, Silva RA, Jansen K, Kuhn RP, Horta BL, Pinheiro RT. Suicidal ideation in adolescents aged 11 to 15 years: prevalence and associated factors. Rev Bras Psiq 2010; 32(1):37-41. with 1,039 adolescents from the urban area of Pelotas in the south of Brazil, both of which showed a strong association between suicidal ideation and depressive symptoms [OR = 10.23; 8.41 to 12.44; CI 95% and OR = 11.25; 4.82 to 26.22, CI 95%, respectively].

However, other studies involving adolescents have reported weaker associations between both variables, including an investigation carried out by Kaess et al.¹⁶16. Kaess M, Parzer P, Haffner J, Steen R, Roos J, Klett M, Brunner R, Resch F. Explaining gender differences in non-fatal suicidal behaviour among adolescents: a population-based study. BMC Public Health 2011; 11:597. in Germany [OR = 1.298; 1.259 to 1.338, CI 95%], another undertaken by Glashouwer¹⁵15. Glashouwer KA, De Jong PJ, Penninx BWJH, Kerkhof AJFM, Van Dyck R, Ormel J. Do automatic self-associations relate to suicidal ideation? Journal of Psychopathology and Behavioral Assessment 2010; 32(3):428-437. in Holland [OR = 1.95; 1.72 to 2.22, CI 95%], and a study conducted by Shilubane et al.²⁰20. Shilubane HN, Ruiter RAC, van den Borne B, Sewpaul R, Reddy J, Reddy P. Suicide and related health risk behaviours among school learners in South Africa: Results from the 2002 and 2008 national Youth Risk Behaviour Surveys. BMC Public Health 2013; 13:926. in South Africa [OR = 1.755]. Two studies in Asia also confirmed this association: a study conducted by Medina et al.¹⁷17. Medina OC, Jegannathan B, Dahlblom K, Kullgren G. Suicidal expressions among young people in Nicaragua and Cambodia: a cross-cultural study. BMC Psychiatr 2012; 12(28):1-7. in Cambodia [OR of 1.328 and 1.164 for women and men, respectively] and another undertaken by Nguyen et al.¹⁹19. Nguyen DT, Dedding C, Pham TT, Wright P, Bunders J. Depression, anxiety, and suicidal ideation among Vietnamese secondary school students and proposed solutions: a cross-sectional study. BMC Public Health 2013; 13(1):1-10. in Vietnam [OR = 3.45; 2.63 to 4.54;, CI 95%,); while in Central America, Medina et al.¹⁷17. Medina OC, Jegannathan B, Dahlblom K, Kullgren G. Suicidal expressions among young people in Nicaragua and Cambodia: a cross-cultural study. BMC Psychiatr 2012; 12(28):1-7. obtained an OR of 1.275 and 1.650 for women and men, respectively, in a study with students aged between 15 and 18 years in Nicaragua.

In Mexico, this association was reported by two recent studies, the first of which²¹21. Pérez-Amezcua B, Rivera-Rivera L, Atienzo EE, De Castro F, Leyva-López A, Chávez-Ayala R. Prevalencia y factores asociados a la ideación e intento suicida en adolescentes de educación media superior de la República mexicana. Salud Publica Mex 2010; 52(4):324-333. reported an OR of 5.36 [4.51 to 6.38, CI 95%] for depressive symptoms and a second²³23. Hidalgo-Rasmussen C, Hidalgo-San Martín A. Comportamientos de riesgo de suicidio y calidad de vida, por género, en adolescentes mexicanos, estudiantes de preparatoria. Cien Saude Colet 2015; 20(11):3437-3445., which obtained an OR of 1.9 [1.0 to 3.3, CI 95%]. Both studies were carried out with schoolchildren in the central and western regions of the country, where socioeconomic status, culture and religion are highly different to those in Chiapas, where religion is a potential protective factor against mental disorders and behavioral problems among adolescents⁵⁰50. Dew RE, Daniel SS, Armstrong TD, Goldston DB, Triplett MF, Koenig HG. Religion/spirituality and adolescent psychiatric symptoms: a review. Child Psychiatry Hum Dev 2008; 39(4):381-398.. It is important to note, however, that further research is necessary to corroborate this hypothesis.

With respect to the association between suicidal ideation and impulsiveness, a study conducted by Nock et al.¹²12. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, Chiu WT, Girolamo G, Gluzman S, de Graaf R, Gureje O, Haro JM, Huang Y, Karam E, Kessler RC, Lepine JP, Levinson D, Medina-Mora ME, Ono Y, Posada-Villa J, Williams DR. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry 2008; 192(2):98-105. obtained an OR of 3.3 (2.8 to 3.8, CI 95%), which is higher than that found by the present study. These variables, when found together with depression, constitute a high-risk factor and modulator for the development of suicidal ideation and suicide plans or attempts⁵¹51. Ganz D, Braquehais MD, Sher L. Secondary prevention of suicide. PolS Medicine 2010: 7(6):e1000271..

One of the limitations of this study is that cross-sectional studies are not able to determine cause-and-effect relationships between different variables. Furthermore, non-probability sampling does not allow for the generalization of results to the entire population of this age group. Finally, it would be interesting to explore the variables examined by this study using different tools used by other studies that are able to capture other aspects such as spirituality, culture and the socioeconomic status of women, which deserve further research.

Despite these limitations, this study makes important contributions to the study of suicidal ideation. In this respect it is important to note that it is the first study on this topic to be conducted in Chiapas and therefore the first to confirm the presence in this region of important risk factors for suicidal ideation highlighted by the literature, such as depressive symptoms and impulsiveness, thus serving as an important input to inform the design of strategies to address this problem.

Adolescents with suicidal ideation require constant monitoring and interventions should play particular attention to feelings of despair⁵²52. Czyz EK. Longitudinal trajectories of suicidal ideation and subsequent suicide attempts among adolescent inpatients. J Clin Child Adolesc Psychol 2015; 44(1):181-193.. Given the lack of counselling services provided in the community, such activities could be developed in the university's tutorial department through the provision of guidance in reflection groups or via individualized psychological care.

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