Effects of impulsive personality on suicide in adolescent depression: The chain mediating of perceived social adversity and security

Abstract

BACKGROUND

Depression is a common mental disorder among adolescents, characterized by a high rate of suicide and self-harm, which not only is devastating to families but also has a negative impact on society. Psychological factors such as impulsive personality, perceived chronic social adversity (PCSA), and sense of security are closely associated with suicide risk in adolescents with depression. Few studies have been conducted on the relationship between these factors.

AIM

To explore the impact of impulsive personality on suicide risk in adolescents with depression and the chain mediating effect between PCSA and sense of security.

METHODS

This study is a retrospective study. A total of 200 adolescents with depression who visited the Guangxi Zhuang Autonomous Region Maternal and Child Health Hospital from January 2021 to December 2023 comprised the study cohort. The PCSA scale, Security Questionnaire, Barratt Impulsiveness Scale, and Beck Scale for Suicide Ideation were used to evaluate depression.

RESULTS

Suicide risk was positively correlated with impulsive personality and PCSA (P < 0.05), whereas sense of security was negatively correlated with suicide risk, impulsive personality, and PCSA (P < 0.05). The total indirect effect of PCSA and sense of security on impulsive personality and suicide risk was 35.43%, with the mediating effect of PCSA and sense of security contributing 16.53% and 15.75%, respectively. PCSA and sense of security exhibited a chain mediating effect between impulsive personality and suicide risk, accounting for 3.15%.

CONCLUSION

The suicide risk of adolescents with depression is significantly associated with impulsive personality, PCSA, and sense of security. Impulsive personality affects the suicide risk of adolescents with depression both directly and indirectly, with the latter occurring via PCSA and sense of security.

Key Words: Adolescents; Suicide risk; Impulsive personality; Perceived chronic social adversity; Sense of security

Core Tip: This study focuses on adolescent patients with depression and examines the relationship between impulsive personality, perceived chronic social adversity (PCSA), sense of security, and suicide risk. An analysis of 200 adolescent patients with depression revealed that their suicide risk was positively correlated with impulsive personality and PCSA and negatively correlated with sense of security. PCSA and sense of security play a chain mediating role between impulsive personality and suicide risk. Reducing the level of PCSA and enhancing the sense of security among adolescents with depression may reduce their suicide risk.

INTRODUCTION

Depression is a common mental disorder in adolescents. Studies have shown that 37% of adolescents have depression, which is the primary risk factor for adolescent suicide[1]. Approximately 17.6%-23.5% of adolescents have seriously considered ending their lives, and adolescent suicide is closely associated with depression[2]. The adverse social and family consequences of adolescent suicide are a growing public health problem. Studies have found that suicidal ideation, which is the first step of suicide, is key to suicide prevention[3]. Among the many factors influencing the suicide risk of adolescent patients with depression, impulsive personality, perceived chronic social adversity (PCSA), and sense of security have attracted significant attention[4]. Impulsive personality is the psychological tendency to respond quickly and unplanned to internal and external stimuli; this often results in adverse effects due to a lack of consideration of the consequences of such behavior. Carballo et al[5] found that impulsive personality markedly increases the risk of suicidal behavior. PCSA, also known as social trauma, refers to an individual’s subjective perception of persistent or recurring negative social events (such as rejection, rejection, and excessive control) in daily life[6]. PCSA causes individuals to lose control of their current state, resulting in confusion, anxiety, and even aggressive behavior. PCSA is reported to be one of the main risk factors for depression, and the more negative events an individual experiences, the greater the possibility of a psychological crisis[7]. According to the stimulus–cognitive–emotion model, an individual’s perception of negative events is a key factor that leads to the occurrence of negative emotions[8]. When PCSA reaches the limit of an individual’s negative cognitive load, depression and suicidal thoughts may arise. Security is the premonition of risk, and it involves a sense of control and certainty when dealing with threats. Several studies have reported that the level of psychological security, which has a negative predictive effect on suicidal ideation, is low among adolescents with depression[9,10]. Most existing studies have examined the relationship between a single factor and the suicide risk among adolescent patients with depression, while there is a lack of research on the interaction among multiple factors. Although some studies involved mediating variables, most have only examined the role of one mediating variable, and there are relatively few studies on the chain mediating effect among variables. Therefore, this study aimed to build a chain mediation model (Figure 1) to evaluate the chain mediating effect of the variables, PCSA and sense of security, on the relationship between impulsive personality and suicidal self-harm risk in adolescents with depression. The results provide new strategies for alleviating suicidal ideation in adolescents with depression.

Figure 1  Conceptual models of suicide risk, impulsive personality, sense of security, and perceived chronic social adversity.

MATERIALS AND METHODS

General information

A total of 200 adolescents with depression who visited the Guangxi Zhuang Autonomous Region Maternal and Child Health Hospital from January 2021 to December 2023 were selected for the study. The inclusion criteria were as follows: The participants must: (1) Meet the diagnostic criteria for depression[11]; (2) Be aged 12-18 years; and (3) Score > 17 on the Hamilton Depression Scale-24. Patients were excluded if they had: (1) Other psychiatric disorders; (2) Other serious conditions including organ lesions and malignant tumors; (3) Participated in other psychological intervention studies; or (4) Exhibited mental retardation or vision, hearing, or speech impairment.

Survey tool

PCSA questionnaire: The PCSA scale established by Zhang et al[12] was used in this study. Scored on a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree) with a total score of 140, the PCSA scale contains 28 items in 3 dimensions: Social exclusion, excessive control, and competitive failure. The PCSA scores of individuals increase with increasing individual scores. The Cronbach’s α coefficient for the questionnaire was 0.95. The scale shows good reliability and validity and is suitable for measuring the PCSA in adolescents with depression. It can better reflect the long-term stress and impact of negative events felt by patients in a social environment.

Security questionnaire: This questionnaire, compiled by Cong and An[13], consists of two dimensions of interpersonal security and a definite sense of control, with 8 entries each. This study used a 5-point Likert scale ranging from “very inconsistent” to “very consistent”, with a total score of 16-80 points; the higher the score, the higher the sense of security. Cronbach’s α coefficient was 0.840. This questionnaire comprehensively assesses the level of security of adolescent patients with depression based on two aspects: Interpersonal communication and the sense of control over the environment.

Barratt impulsiveness scale: This scale was validated by Lau et al[14], and it includes 3 dimensions impulsiveness, namely, cognitive, motor, and unplanned, with 10 items each. Scored on a 5-point Likert scale (1 = “not”; 5 = “always”), the assessment yields a total score ranging from 30 to 150 points, with higher scores indicating stronger impulsivity. Cronbach’s α coefficient was 0.80. This scale has high reliability and validity and can accurately assess the impulsivity of an individual in different dimensions, thereby providing a reliable basis for studying the relationship between impulsive personality and suicide risk.

Beck scale for suicide ideation: This scale was validated by Kliem et al[15], and it includes 2 dimensions of suicidal ideation (5 items) and suicidal tendency (14 items), with a total of 19 items. The scale is graded at 3 levels (0 = “no”, 1 = “medium”, and 2 = “strong”), with a total score of 0-38 points. The higher the score, the stronger the suicidal ideation and the higher the suicide risk. Cronbach’s α coefficient for this scale was 0.860. This scale is a classic tool for assessing suicide risk. It can measure the tendency for suicidal ideation among adolescent patients with depression relatively accurately, thus providing an effective assessment method for studying suicide risk.

Investigation method

After obtaining informed consent from the participants, the research team followed standardized guidelines to explain the contents of the questionnaire to the patients in detail and instructed them to give answers that closely align with their current situation. The questionnaire was filled out on the spot for review; therefore, any problems could be identified in time to fill the gaps.

Statistical analysis

Statistical analysis was performed using SPSS 23.0 software. Measurement data were expressed as the mean ± SD and were compared between groups using a t-test. Count data use cases (%) were expressed, and a χ² test was used for comparison. The Harman single-factor test and Pearson correlations were used for the common method deviation test and correlation analyses, respectively. The SPSS-process macro was used for mediating effect analysis. The significance value was set at P < 0.05.

RESULTS

Demographic data

A total of 210 questionnaires were sent out, of which 10 were inconsistent and 200 were valid, with an effective recovery rate of 95.24%. A total of 200 patients were included in this study, of whom 48.00% were female and 52.00% were male. Junior (aged 12-15 years) and senior (aged 15-18 years) high school students accounted for 38.00% and 62.00% of the sample, respectively. Other demographic variables are shown in Table 1.

Table 1 Basic information of research objects (n = 200).

Variables	Categories	n	Proportion (%)
Gender	Female	96	48.00
	Male	104	52.00
Age (years)	12-15	76	38.00
	15-18	124	62.00
Grade level	Junior high school	76	38.00
	Senior high school	124	62.00
Only child	No	98	49.00
	Yes	102	51.00
Monthly household income (yuan)	< 2000	55	27.50
	2000-5000	76	38.00
	> 5000	69	19.50
Family history of depression	No	155	77.50
	Yes	45	22.50
Parental marital status	At marriage	101	50.50
	Divorced/widowed	99	49.50

Common method bias

Common method bias was tested using the Harman single-factor test. The results indicated that five of the unrotated eigenroots had factors > 1. The first factor accounted for 28.44% of the variation, falling below the critical threshold of 40%. Therefore, the data in this study do not show a significant common methodological bias.

Analysis of demographic data

There was no significant effect of demographic variables on the difference between the scores on each scale. As shown in Table 2, an independent sample t-test was conducted on gender for the dimensions of suicide risk, impulsive personality, sense of security, and PCSA. No significant difference was observed in the above variables between the students of different genders (P > 0.05), suggesting that gender factors do not influence these psychological dimensions.

Table 2 Gender differences in suicide risk, impulsive personality, sense of security, and perceived chronic social adversity (mean ± SD).

Variables	Male	Female	t	P value
Suicidal ideation	6.81 ± 0.64	6.79 ± 0.71	0.168	0.867
Suicidal tendency	18.06 ± 3.28	17.89 ± 2.94	0.390	0.697
Suicide risk	24.87 ± 3.39	24.68 ± 3.06	0.412	0.681
Cognitive impulse	35.48 ± 3.74	35.82 ± 3.39	0.677	0.499
Motor impulsivity	31.76 ± 3.00	31.51 ± 3.37	0.553	0.581
Unplanned impulsivity	39.98 ± 3.84	40.24 ± 4.26	0.451	0.652
Impulsive personality	107.22 ± 5.93	107.57 ± 6.2	0.409	0.683
Interpersonal security	22.54 ± 3.82	22.99 ± 3.44	0.875	0.382
Definite sense of control	17.53 ± 3.29	17.90 ± 3.10	0.810	0.419
Sense of security	40.08 ± 4.49	40.89 ± 4.60	1.257	0.210
PCSA	59.06 ± 6.54	58.27 ± 5.84	0.894	0.372

PCSA: Perceived chronic social adversity.

Correlation analysis of suicide risk, impulsive personality, sense of security, and PCSA

Among the 200 patients, the suicide risk score was 24.78 ± 3.23, the impulsive personality score was 107.396.06, the PCSA score was 58.68 ± 6.22, and the safety score was 40.46 ± 4.55. Correlation analysis revealed suicide risk to be positively correlated with impulsive personality and PCSA (P < 0.05), while security to be negatively correlated with suicide risk, impulsive personality, and PCSA (P < 0.05) (Table 3).

Table 3 Correlation analysis of suicide risk, impulsive personality, sense of security and perceived chronic social adversity (r).

Variables	Suicide risk	Impulsive personality	Sense of security	PCSA
Suicide risk	1	-	-	-
Impulsive personality	0.239b	1	-	-
Sense of security	-0.244b	-0.277b	1	-
PCSA	0.230b	0.271b	-0.250b	1

^bP < 0.01.

PCSA: Perceived chronic social adversity.

Chain mediation model validation

With impulsive personality as the independent variable, suicide risk as the dependent variable, and PCSA and sense of security as the mediating variables, the mediating effects of security and PCSA on the relationship between impulsive personality and suicide risk were evaluated using the SPSS-PROCESS macro (Figure 2 for the model). The results indicated that impulsive personality positively predicted PCSA and suicide risk and negatively predicted security. PCSA positively predicted suicide risk and negatively predicted security, while security negatively predicted suicide risk (Table 4). Using the Bootstrap program, 5000 repeated data samplings were used to test the mediating effect. PCSA and sense of security did not contain 0 in the 95% confidence interval of impulsive personality and suicide risk, indicating that the mediating effect was significant. For the analysis of the chain mediation effect between PCSA and sense of security, 95% confidence intervals do not include 0, indicating that the chain mediation effect is significant; the indirect effect size is 0.004, accounting for 3.15% of the effect (Table 5).

Figure 2 Model diagram of the chain mediating effect of impulsive personality on suicide risk. ^aP < 0.05, ^bP < 0.01, ^cP < 0.001.

Table 4 Regression analysis of intermediate variables.

	PCSA		Sense of security		Suicide risk
	β	t	β	t	β	t
Impulsive personality	0.278c	3.957	-0.169c	-3.229	0.082a	2.145
PCSA			-0.139b	-2.711	0.076a	2.065
Sense of security					-0.116a	-2.301
R2	0.271		0.331		0.333
F	15.658		12.151		8.136

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

PCSA: Perceived chronic social adversity.

Table 5 Mediating effect analysis between perceived chronic social adversity and sense of security.

Variables	Effect size	SE	95%CI	Effect ratio (%)
Total effect	0.127	0.037	0.055-0.200	-
Direct effect	0.082	0.038	0.007-0.157	64.57
Total indirect effect	0.045	0.018	0.015-0.082	35.43
Impulsive personality→PCSA→suicide risk	0.021	0.013	0.001-0.050	16.53
Impulsive personality→sense of security→suicide risk	0.020	0.011	0.002-0.045	15.75
Impulsive personality→PCSA→sense of security→suicide risk	0.004	0.003	0.001-0.013	3.15

PCSA: Perceived chronic social adversity.

DISCUSSION

Current situation analysis of suicide risk, impulsive personality, PCSA, and sense of security in adolescents with depression

Depression is primarily characterized by low mood, anhedonia, as well as high suicide and self-harm rates[16]. Adolescence is a special period when personal character is shaped; general self-awareness is strong; and past traumatic experiences, current conflicts, and pressures are difficult to solve in a timely and effective manner. During this period, individuals are more likely to experience deviations in personality, emotions, and behaviors and develop suicidal ideation or behavior to manage pain. In this study, the suicide risk score of adolescents with depression (24.78 ± 3.23) was at a medium level. Therefore, healthcare professionals must closely monitor suicidal risk in adolescents with depression, help them establish healthier life values, and avoid adverse outcomes caused by depression or suicidal intentions. In this study, the impulsive personality score of adolescents with depression (107.39 ± 6.06) was above the average level and higher than those reported by Fu et al[17] in his study on college students. This indicates that adolescent patients with depression are more likely to exhibit impulsive behaviors when facing stress and experiencing strong negative emotions caused by low adaptability and limited ability to deal with problems in the face of pressure, family conflicts, punishment, and other problems.

In this study, the PCSA score of adolescents with depression was 58.68 ± 6.22, which was at a medium level, but higher than those reported by Yu and Zhao[18] in his study on college students. Interpersonal communication, academic pressure, and emotional pressure are major stressors for adolescents with depression[19], resulting in their perception of a psychological burden. Negative events such as academic failure, peer alienation or rejection, and constraints from others lead to a strong sense of alienation, frustration, and helplessness in adolescents with depression, thus increasing their suicidal risk. Furthermore, lack of security affects the adolescents’ ability to adapt to their environment and increases the likelihood of adopting negative coping strategies such as avoidance and withdrawal[20]. In this study, the sense of security scores of adolescents with depression (40.46 ± 4.55) was at a medium level, which was consistent with those reported by Niu et al[21]. First, social dysfunction is the main reason for the decreased sense of security in adolescents with depression. Social anxiety, shyness, and a lack of good friendships result in feelings of isolation and helplessness, which may cast doubt on their social abilities and reduce their sense of security. Second, family conflicts, domestic violence, divorce, and other familial issues lead to instability and a loss of security in adolescents with depression by directly affecting their psychological state.

Mediating role of PCSA

PCSA showed a 16.53% mediating effect between impulsive personality and suicide risk. Impulsive personality traits include being impatient, unwilling to take the time for thoughtful and detailed analyses, and thrill seeking for instant gratification. This leads to poor executive function, difficulty in focusing on processing information and making rational decisions, and continuous and passive immersion in negative emotional states, which further increases PCSA. As adolescents with depression feel intense despair when immersed in negative emotions, they struggle to overcome any predicament or change their views and negative emotions, thus increasing suicidal ideation. Jankowski et al[22] observed that impulsive personality significantly increases the risk of suicide, which is closely associated with PCSA. Moreover, according to the interpersonal theory of suicide, suicidal ideation turns into suicidal behavior when an individual experience painful events repeatedly[23], while the connotation of PCSA is more inclined to the repeated perception of negative information in daily life, which makes it easier for an individual to acquire suicidal ability and thereby suicide risk. Therefore, to prevent the occurrence of suicide in adolescents with depression, families and schools should pay attention to their changes in PCSA and emotional behavior and provide psychological support and intervention as necessary.

Mediating effect of sense of security

The mediating effect of security between impulsive personality and suicide risk was 15.75%. The adolescent emotions are characterized by polarized, impulsive, and irritable behavior with poor self-control, which may cause harmful behaviors when stimulated by stress. Impulsive personality in adolescents with depression has been reported to cause difficulty in adapting to their environment. Lack of security in the face of stressful events results in excessive attention to negative environmental information and a feeling of urgency and anxiousness. As a result, reckless and risky decisions are made, which increases the risk of injury or danger, affects psychological security, and reduces self-control[24]. Therefore, it is recommended that parents of adolescents with depression modify their communication, discipline, and emotional connection. Family members are encouraged to express their true feelings to understand and provide support for these adolescents, thereby helping them to reestablish a new parent–child relationship and improve their psychological security. In addition, schools and communities can help adolescent patients with depression enhance their psychological resilience and improve their ability to cope with stress through mental health education and counseling.

Chain mediating effect of PCSA and sense of security

In this study, PCSA and sense of security had a 3.15% chain mediation effect between impulsive personality and suicide risk. As a psychological tendency, an impulsive personality makes it difficult for individuals to take the initiative to solve challenges and pressures and to conduct deliberate logical analysis and calm thinking, thus increasing their sensitivity to social adversities[25]. An increase in PCSA further intensifies the psychological pressure on individuals and weakens their sense of security. The sense of security, as an internal feeling of risk premonitions, is negatively correlated with suicide risk. Persistent or repeated negative social events experienced by adolescents with depression may cause them to feel helpless, which weakens their sense of control over their environment and certainty about the future; this leads to a decreased sense of security, which may, in turn, trigger more intense suicidal ideation[26].

It is clinically possible to enhance the sense of security of adolescents with depression by reducing PCSA levels, thereby reducing suicide risk. First, families must strive to enhance their communication and support, reduce conflicts, and help adolescent patients with depression establish a more stable family environment, thereby increasing their sense of security. Second, schools can offer mental health education courses to help adolescent patients with depression enhance their psychological resilience and improve their ability to cope with stress. Moreover, schools should establish a mental health monitoring mechanism to promptly identify and provide interventions for high-risk students. In addition, the community can organize mental health promotion activities to enhance public awareness and understanding of depression among adolescents and reduce social prejudice and discrimination. The community can also provide mental health counseling services to offer timely psychological support for adolescent patients with depression. However, these intervention strategies have certain limitations in different clinical settings. For example, in areas with limited resources, schools and communities lack sufficient mental health professionals and financial support, making it difficult to implement comprehensive mental health education and intervention activities. Furthermore, the effect of family intervention may be influenced by the degree of cooperation among family members and the family environment. Therefore, when implementing intervention strategies, adjustments and optimizations are needed based on specific circumstances to ensure the effectiveness and sustainability of the intervention measures.

CONCLUSION

This study establishes the chain mediation effect of PCSA and sense of security on the relationship between impulsive personality and suicide risk in adolescents with depression, thereby confirming that impulsive personality can indirectly affect suicide risk in adolescents with depression by regulating PCSA and sense of security. The study limitations are as follows: The sample population was from a single center, and the long study period might have caused selection bias and impacted the study results. In addition, the cross-sectional survey conducted in this study must be validated by multi-center large-sample studies in the future.