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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20

Mediating Effects of Stress, Weight-Related Issues, and Depression on Suicidality in College Students ab

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Sydney S. Smith MS , Jocelyn Smith Carter PhD , Sabrina Karczewski MA , Bernadette a

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Pivarunas BS , Shannon Suffoletto MA, LCPC, BC-DMT & Art Munin PhD

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Department of Psychology DePaul University Chicago, Illinois

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Department of Psychology University of South Carolina Columbia, South Carolina

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Office of Health Promotion and Wellness DePaul University Chicago, Illinois

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Dean of Students DePaul University Chicago, Illinois

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Assistant Vice President/Dean of Students, Illinois State University, Normal, Illinois Accepted author version posted online: 15 Sep 2014.Published online: 24 Nov 2014.

Click for updates To cite this article: Sydney S. Smith MS, Jocelyn Smith Carter PhD, Sabrina Karczewski MA, Bernadette Pivarunas BS, Shannon Suffoletto MA, LCPC, BC-DMT & Art Munin PhD (2015) Mediating Effects of Stress, Weight-Related Issues, and Depression on Suicidality in College Students, Journal of American College Health, 63:1, 1-12, DOI: 10.1080/07448481.2014.960420 To link to this article: http://dx.doi.org/10.1080/07448481.2014.960420

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JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 63, NO. 1

Major Article

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Mediating Effects of Stress, Weight-Related Issues, and Depression on Suicidality in College Students Sydney S. Smith, MS; Jocelyn Smith Carter, PhD; Sabrina Karczewski, MA; Bernadette Pivarunas, BS; Shannon Suffoletto, MA, LCPC, BC-DMT; Art Munin, PhD

Suicidality Rates in College Students uicide is the third leading cause of death for those individuals between the ages of 15 and 24.1 Suicide leads to approximately 1,110 deaths a year within the US college student population.2 In a recent survey distributed to 157 colleges, death by suicide was the second leading cause of death overall and occurred at a rate of 6.17 per 100,000.3 These prevalence rates demonstrate how extremely important it is to investigate particular risk factors that uniquely contribute to suicidality in a sample of young adults in college. Suicidal behavior encompasses 3 different types of selfdirected violence. The Centers for Disease Control and Prevention define suicidal ideation as planning, thinking about, or considering suicide, a suicide attempt as intentionally acting in a way to incur death on oneself that may or may not result in self-injury as a consequence, whereas suicide is the actual death that results from the intentional act of killing oneself.4 In the current study, the term suicidality refers to the serious consideration of suicide, or suicidal ideation, suicide attempts, and intentional self-injurious behaviors experienced by college students. Holistic health considers all dimensions of a person’s health and puts the individual at the center of health maintenance. Many responses to health-related problems, stress included, have broadened to consider approaches that are all-inclusive and integrative. This approach to health can challenge aspects of our society that contribute to stress or lead to ill-health.5 Suicidality, a multifaceted and complex mental health issue college students may face, is an entity that necessitates a holistic health perspective. College students experience major life transitions as they enter new, unfamiliar environments, encounter difficult

Abstract. Objective: Through a holistic health lens, the current study examines the effects of weight-related issues and stress on suicidality while controlling for depressive symptoms in college students. Participants: In total, 872 undergraduate and graduate students at DePaul University completed the American College Health Association–National College Health Assessment II Webbased survey in Spring 2010. Methods: Measures of suicidality, depression, weight-related issues, and life stressors were assessed, along with gender differences. Results: Females reported experiencing more weight loss attempts and total stressors than males. Weight-related issues and stress both significantly predicted depressive symptoms in a path analysis; depressive symptoms, in turn, significantly predicted suicidality. Gender differences were found; depressive symptoms mediate the relation between stress and suicidal behavior for females but not for males. Implications: This investigation furthers previous research on suicidality in college students and suggests that all-inclusive interventions that address weight-related issues and stress may help reduce depressive symptoms, which then may reduce suicidal behavior.

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Keywords: depression, stress, suicide, weight

Ms Smith was with the Department of Psychology at DePaul University in Chicago, Illinois, at the time of the study and is now with the Department of Psychology at the University of South Carolina in Columbia, South Carolina. Dr Smith Carter, Ms Karczewski, and Ms Pivarunas are with the Department of Psychology at DePaul University in Chicago, Illinois. Ms Suffoletto is with the Office of Health Promotion and Wellness at DePaul University in Chicago, Illinois. Dr Munin was Dean of Students at DePaul University in Chicago, Illinois, at the time of the study and is now Assistant Vice President/Dean of Students at Illinois State University in Normal, Illinois. Copyright Ó 2015 Taylor & Francis Group, LLC 1

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academic and social pressures, and leave behind established familial and peer support systems.6 Additionally, alcohol and drug use, as well as associated substance abuse disorders, occur at particularly high rates in college students and serve as risk factors for both depression and suicide.7–10 Research has also demonstrated that impulsivity, a trait commonly expressed by adolescents and young adults, is an additional risk factor for suicidal behavior, thereby creating a specific vulnerability in college-aged individuals.8,11 Gender differences exist in suicide rates such that in the general population as well as in college samples, females are more likely to experience suicidal ideation and attempt suicide than their male counterparts, whereas males are more likely to complete suicide.12–15 Although research has shown college students to be susceptible to suicidal behaviors, similarly aged young adults not attending college have demonstrated even higher levels of suicidality.16–18 In one study examining rates of suicide across 12 different Midwest colleges, researchers found that the incidence of suicide in college students was 50% of the suicide rate found in a national sample of noncollegiate young adults matched on age, ethnicity, and gender.18 College attendance may actually serve a protective role, as it provides increased availability and accessibility to a variety of holistic support system, including peer support, health services, professors, counseling centers, and spiritual groups.10,18 Although young adults not attending college have a higher risk for suicidal behavior, access to these support systems may not completely mitigate the risk for college students, as students still face a multitude of stressors and are subjected to particular vulnerabilities such as depression and weight-related issues or body image concerns that lead to suicidality.

Predictors of Suicidality Depression Suicidal ideation and behaviors are closely linked with depressive mood. Suicidal ideation and behavior are diagnostic features of a major depressive episode.19 Suicidality has also been associated with nondiagnostic features of depression, including rumination, hopelessness, emotional lability, and social withdrawal.20 Cross-sectional and longitudinal research has consistently demonstrated associations between depression or depressive symptoms and suicidal behavior.21–25 In the existing cross-sectional literature, rates of depression amongst college students have been consistently positively associated with current suicidal ideation.26–28 The longitudinal relationship of child-onset major depression and dysthymia predicting higher rates of suicidal behaviors in late adolescence29 has been established. Additionally, in a community sample of adults, a number of depressive symptoms significantly predicted suicidal ideation 5 years later when controlling for previous suicidality.30 Particularly, depressive symptoms predicted persistent suicidal 2

ideation and created significant risk for later suicide plans or attempts in a sample of college students examined prospectively over 4 years.2 Thus, depression and suicidal ideation and behaviors are cross-sectionally and longitudinally related in both the general and college populations. Weight Overweight status and obesity, perceived weight, ineffective attempts at weight loss, and weight dissatisfaction are potential predictors of suicidality that have not been adequately studied apart from the effects of depressive symptoms in a college population.26,31–33 Body mass index (BMI), body weight perception, and weight loss attempts and practices have been demonstrated to be strongly associated in a college sample,34 lending support to the idea that these factors may represent a latent construct of weightrelated issues. Further support for a single construct comes from a study in which overweight and obese university students reported the highest levels of dissatisfaction with their weight.35 In this sample, all overweight females expressed a desire for a weight lower than their current weight. Thus, objective and subjective measures of weight, along with other weight-related concerns and behaviors, are related and therefore should be examined jointly, as they may predict similar mental health outcomes. Weight-related perceptions and behaviors have been demonstrated to predict suicidal ideation and behaviors in college-attending young adults. In one cross-sectional study, self-perceived obesity was a significant independent predictor of recent suicidal ideation in a college sample.26 Feelings of body uneasiness, including concerns surrounding one’s current weight, was associated with greater suicide risk in a sample of college students in a cross-sectional analysis.31 In addition, female college students who engaged in unhealthy weight loss practices were 2 to 3 times more likely to engage in highly risky sexual behaviors,36 lending support to the potential link between weight loss attempts and other impulsive, high-risk behaviors, such as suicidal behaviors. Eating disturbances as well as overexercise, associated with attempts to lose weight, were significantly associated with increased suicidal behaviors in college students.32,33 Thus, a collection of perceptions and behaviors related to weight are linked to suicidal behaviors in college populations.37 More research is necessary to explicate the nature of the relationship between weightrelated issues and suicidality in the vulnerable college population. Importantly, weight status, weight perception, body dissatisfaction, and weight loss attempts are highly associated with depressive symptoms in the general population,23,28,38–40 with a cyclical or bidirectional causal mechanism supported by the literature.41 Further research is needed to tease apart the effects of weight-related issues and depression on suicidality so as to provide more targeted and effective prevention and intervention efforts for the college population. JOURNAL OF AMERICAN COLLEGE HEALTH

Effects of Stress, Weight Issues, and Depression on Suicidality

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Stressors Life stressors are consistently associated with suicidal ideation and behaviors. Specific stressors or reminders of them (ie, anniversaries of events) are often identified as the precipitating factor leading to a suicide attempt.42,43 Certain stressors, such as romantic break-ups, interpersonal loss, legal problems, and financial difficulties, have been well studied and seem to have a particularly strong impact on suicidal thoughts and actions.44–46 Less research has been conducted on cumulative stressful life events, particularly within a college population. However, one study stipulated that stressful life events longitudinally predicted suicidality amongst youth and young adults with a specific genetic expression.47 Concomitantly, in adolescence, those who attempted suicide were more likely to report more frequent and severe life stressors than those who had not attempted suicide.48 In another study, researchers examined overall negative life stress and found it to be an independent predictor of suicidal ideation.49 Additionally, subjective experience of life stressors may be more important in predicting suicidality. A recent study demonstrated that emotional distress explained the relationship between external life events and suicidal intent in US soldiers who had attempted suicide.50 Greater emotional distress and thoughts related to trauma also predicted shorter deliberation time regarding the decision to commit suicide.50 No similar research has been done with a civilian or college sample. More research is needed to understand the holistic relationship between cumulative life events, related subjective distress, and suicidal ideation and behaviors.

Stress, Weight-Related Issues, and Depressive Symptoms Depressive symptoms, weight-related concerns and practices, and stress are all predictive of suicidality in samples of college students, but no research to date has integrated these factors into a single model that examines the pathways through which they influence suicidality. Although previous research shows that a variety of weight factors and stress have direct associations with suicidality, they are also both associated with depressive symptoms. Stressors and subjective stress reactivity consistently predict depression in longitudinal studies.51–55 Also, BMI,56– 58 weight loss attempts,40,59 and perceived weight status60 are all predictive of depressive symptoms in longitudinal studies. Thus, it is possible that depressive symptoms mediate the effects of stress and weight-related concerns on suicidality. Although research reveals that weight-related issues and stress predict depression and that depression predicts suicidality longitudinally, there has yet to be a study inspecting the potential mediational model involving all of these constructs together. Studies have illustrated the VOL 63, JANUARY 2015

important associations between the constructs of interest, as one study noted the high correlations between life stress, depression, and unhealthy eating behaviors.61 Given previous research, depression likely serves as an important mediator in the causal chain between weightrelated issues and suicidality. For example, the perception of being overweight significantly predicted depression, and both overweight perception and depression predicted suicidal ideation in a longitudinal study following adolescents into young adulthood,62 suggesting the partial mediation of depression on the relation between weight perception and suicidality.37 Another study found depression and aggressiveness to mediate the relation between eating disorder symptoms and suicidal ideation in a sample of older youth.63 Depression, along with hopelessness, has also been found to fully mediate the relation between negative life events or stressors and suicidal ideation in college students.27,64,65 One study found self-esteem and depression to mediate the relation between stressful life events and suicidal ideation in a sample of college students,66 further demonstrating the importance of investigating a comprehensive model with weight-related concerns and practices, stress, and depression. However, none of these studies integrated weight-related issues, stress, depression, and suicidal ideation through the holistic health lens revealing a gap in the literature to be addressed. Gender Previous research findings have exhibited gender differences in the factors that create risk for or protection from suicidality. Research shows that female college students have less accurate body perceptions as well as engage in dieting behavior and other unhealthy weight management practices more frequently than male college students.67,68 Female college students also exhibit greater appearancebased rejection sensitivity than their male counterparts.69 Those females engaging in weight loss attempt practices, as well as those with distorted body images, are also more likely to report depressive symptoms than males engaging in similar weight-loss behavior.59,68 Furthermore, the relationship between self-perceived weight status and depressive symptoms is stronger in females.15 It is also important to note that the relationship between weight factors and depression may operate differently between males and females. For example, higher BMI in females was associated with major depression and suicidal ideation, whereas lower BMI in males was associated with major depression, suicidal ideation, and suicide attempt.70 This finding coincides with research that has found the desire to both lose and gain weight in college males and a tendency to prefer a weight within their current BMI range, whereas the majority of college females desired to weigh lighter and to be within a lower BMI range.35 Research discusses how males may be more concerned with body composition rather than weight-related factors, as ideals of 3

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muscularity are more important for males. 35,71,72 Body dissatisfaction and disordered eating practices were related to perceptions of being less muscular in a sample of college males, which was strongly linked to depression.73 Thus, complex relations concerning weight-related issues, depression, and gender exist and necessitate further understanding. Gender differences in the relation between depressive symptoms and suicidal behaviors are also demonstrated in the literature. One study found that depressive symptoms predicted suicidal ideation in college female students, whereas alcohol-related problems and familial social support predicted suicidal ideation for college male students.74 Adverse life events are especially prevalent in young adult males and events such as relationship breakdowns, financial issues, bereavement, and illness most commonly lead to male suicidal behavior.75 Research examining the mechanisms underlying the link between stress and suicidal behaviors has presented gender discrepancies as well. One previous study noted that mediators in the relationship between childhood stressors and adult suicide risk differed by gender, as the pathway for females was mediated by depression and alcohol problems, whereas the pathway for males was mediated by low self-esteem.36 Overall, these findings indicate that depression may be more important in predicting suicidality and mediating the relation between stress and suicidality for females, but not for males. This research further indicates that stressful life events and selfesteem components, such as body and weight perception or dissatisfaction, may be more important in directly predicting suicidality for males. Given discrepancies found in the literature as well as the lack of research examining gender as a moderator in the proposed comprehensive model, further research is needed to disentangle gender differences in the different relations between depression, weight-related issues, stress, and suicidality. Current Study The purpose of the current study is to examine the joint effects of weight-related issues and stress on suicidality in college students while controlling for depressive symptoms. Specifically, we predict that depression will mediate the effects of weight-related issues and stress on suicidality, but that stress will have a direct effect on suicidality. Furthermore, we predict that gender differences will emerge from relations within the mediational model. Specifically, the current study will address the following research questions and hypotheses. First, weight-related issues and stress will predict depressive symptoms. Second, depressive symptoms will mediate the relation between weight-related issues and stress and suicidality. Third, stress will directly predict suicidality. Fourth, gender differences will exist in the model such that depression will predict suicidality, and depression will mediate the relation between stress and suicidality along with the relation between weight-related issues and suicidality in females, but not males. 4

METHODS Procedure Data were gathered through the use of the American College Health Association–National College Health Assessment (ACHA-NCHA) II, a Web-based survey organized by the ACHA assessing different aspects of students’ health. The surveys are self-selected by participating schools across the country, which then randomly select students to participate. One hundred thirty-nine self-selecting institutions utilizing random sampling completed the survey in the Spring of 2010, resulting in 95,712 surveys.76 Reliability and validity analyses were conducted for the ACHA-NCHA by examining comparisons with 4 nationally representative databases: National College Health Risk Behavior Survey Centers for Disease Control and Prevention (CDC) 1995, Harvard School of Public Health 1999 College Alcohol Study (CAS), United States Department of Justice: The National College Women Sexual Victimization Study 2000 (NCWSV), and the ACHA-NCHA 1998, Spring 1999, and Fall 1999 Pilots and ACHA-NCHA Spring 2000.77 Percentages were compared and item reliability analyses were performed examining similar items between these databases. Further, construct validity and measurement validity analyses were conducted comparing results of the ACHANCHA with results derived from these data sets. Overall, the ACHA-NCHA was found to be reliable and valid in evaluating and representing students throughout the country. Surveys were administered in the spring of 2010 to 4,000 DePaul University students via email with a response rate of 21.9%.78 As an incentive, participants who completed the survey were entered in a raffle to win one of ten $50 iTunes gift cards, a TV, and a blue-ray disc player. Fifteen close-ended survey questions concerning depression, weight, stress, and suicidality were used and analyzed in this study. Missing values were excluded from the analysis of items. Institutional review board approval was received in order to conduct analyses for the current study.

Participants Participants consisted of 872 undergraduate and graduate students (62.2% female) attending DePaul University aged 18 to 30C years. DePaul University is an urban, private university that had a total enrollment of 22,741 in the spring of 2010, of which 15,158 were undergraduate students and 7,583 were graduate students. The sample was 76% white, 8.5% Asian or Pacific Islander, 7.8% Hispanic or Latino/a, 6.8% black, 3.4% biracial, 0.7% American Indian, Alaskan Native, or Native Hawaiian, and 1.4% other. Eight participants reported having received a diagnosis and/or treatment for anorexia or bulimia in the past year. The demographic survey results roughly mirror the DePaul University population, as women are overrepresented by 9% and white students are overrepresented by 18%. JOURNAL OF AMERICAN COLLEGE HEALTH

Effects of Stress, Weight Issues, and Depression on Suicidality

Measures

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Depressive Symptoms Depressive symptoms were measured by asking students 6 different questions encompassing specific symptoms of depression experienced during the last 12 months. These 6 items included “Have you ever felt things were hopeless?” “Have you ever felt overwhelmed by all you had to do?” “Have you ever felt exhausted (not from physical activity)?” “Have you ever felt lonely?” “Have you ever felt very sad?” “Have you ever felt so depressed that is was difficult to function?” Response choices were narrowed and modified to demonstrate whether students had or had not endorsed experiencing these symptoms at any time during the last 12 months and consisted of “Yes” or “No.” Items were summed and the item asking about suicidal behavior was removed to reduce contamination among constructs. In the present sample, good internal consistency was found between items (a D .83). Weight-Related Issues Weight-related issues were assessed by 6 items. Selfdescribed weight consisted of students self-reporting their perception of their current weight status by answering the question “How would you describe your weight?” This measure was coded to indicate if the student perceived themselves to be at their desired weight or if they perceived themselves as overweight. Desire for weight change was measured by endorsement of the response option “Lose weight” to the question, “Are you trying to do any of the following about your weight?” Weight loss attempts was measured by asking 4 questions assessing different weightloss strategies. The questions “Within the last 30 days, did you do any of the following: Exercise to lose weight? Diet to lose weight? Vomit or take laxatives to lose weight? Take diet pills to lose weight?” were asked of students to which a “Yes” or “No” response was given. Internal consistency was satisfactory for weight-related issues items (a D .63). General Stress To measure stressor frequency, students were asked whether or not any of the following 12 stressors had been traumatic or very difficult to handle within the last 12 months: Academics, Career-related issues, Death of a family member or friend, Family problems, Intimate relationships, Other social relationships, Finances, Health problem of family member or partner, Personal appearance, Personal health issue, Sleep difficulties, or Other. Subjective experience of stress was assessed by asking the question “Within the last 12 months, how would you rate the overall level of stress experienced?” Five response choices were available and consisted of “no stress,” “less than average stress,” “average stress,” “more than average stress,” and “tremendous stress.” Items were then summed and averaged and adequate internal consistency was found (a D .79). VOL 63, JANUARY 2015

Suicidality Feelings of suicidality were measured by asking 3 questions: “Have you ever seriously considered suicide?” “Have you ever attempted suicide?” and “Have you ever intentionally cut, burned, bruised, or otherwise injured yourself?” Original responses for items consisted of “Never,” “Not in the last 12 months,” “In the last 2 weeks,” “In the last 30 days,” and “In the last 12 months.” The variables were further modified to assess if students had replied “Yes” to experiencing the suicidal behavior any time within the last 12 months or “No” if they had not engaged in the suicidal behavior any time within the last 12 months. Items were summed and internal consistency was adequate (a D .64). RESULTS Preliminary Analyses The most frequently endorsed stressors constituting the stress total variable were Finances, Academics, and Careerrelated issues. Correlation analyses showed that variables were significantly related to each other in the expected direction, as seen in Table 1. Significant gender differences emerged for variables such that females reported higher levels of weight loss attempts and total stress. Full details can be seen in Table 2.

Mediation Model Results for the Entire Sample The mediation model in which depression mediated the relation between stressors and weight-related issues and suicidality was examined in the entire sample using path analysis in AMOS 18.0 (AMOS Development Corporation, Crawfordville, Florida) (see Figure 1). The stress latent variable included 2 manifest variables representing stress: total amount of stressors in various domains in the past year and perceived level of stress in the past year. The weight-related issues latent variable contained 3 variables representing perceived weight category, desire for weight change, and weight loss attempts. Both latent variables were modeled to have direct effects on stress as well as mediated effects that went through the depression variable. Model fit was assessed through the use of several fit indices: the chi-square statistic, comparative fit index (CFI), and root mean square error of approximation (RMSEA). A nonsignificant chi-square value, CFI values above .90, and RMSEA values below .06 typically signify well-fitting models.62 Mediation was examined using methods for testing in longitudinal structural equation modeling.33 The full model included a direct path from the independent variables (weight and stress) to the dependent variable (suicidality) as well as the mediation paths of interest (path a: weight to depression; path b: stress to depression; path c: depression to suicidality). Reduced models that constrained the mediation paths (a, b, and c) of interest to 5

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TABLE 1. Correlations Among Study Variables

1 2 3 4 5 6 7

Subjective experience of stress Stressor frequency Desire for weight change Weight loss attempts Self-described weight Depressive symptoms—no suicide Suicidality

1

2

3

4

5

6

7

— .417** .126** .133** .134** .346** .198**

— .105** .170** .122** .438** .246**

— .482** .380** .026 .062

— .349** .109** .020

— .011** ¡.043

— .135**

—

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Note. Subjective experience of stress measures how students rated their overall level of stress in the last 12 months. Stressor frequency measures how many stressors students endorse as traumatic or difficult to handle within the last 12 months. Desire for weight change measures the intention to lose weight. Weight loss attempts measures if students exercised, dieted, vomited, or took laxatives, or took diet pills in order to lose weight. Selfdescribed weight measures whether students perceive themselves as overweight. **Correlation is significant at the .01 level (2-tailed).

zero were then compared with the full model to determine whether there was a significant change in chisquare fit. A significant change in chi-square fit for both mediational paths (a and c or b and c) provides evidence of a nonzero product term that is consistent with mediation.33 The proposed mediation model for the entire sample provided a good fit to the data (x2 D 5.95, df D 10, p < .001; CFI D .98; RMSEA D .04). In this model, stress (b D .64, p < .001) and weight-related issues (b D ¡.11, p < .05) both significantly predicted depressive symptoms. Stress (b D .45, p < .001), but not weight-related issues, also had a direct effect on suicidality. Depressive symptoms significantly predicted suicidality (b D ¡.13, p < .05). The latent stress and weight-related issues variables were significantly correlated (R D .30, p < .05). Model comparisons were conducted to see whether the mediation paths of interest could be removed without significantly worsening model fit.33 Removing the 3 mediation paths resulted in a significantly worse chi-square fit (Dx2 D 216.06, df D 3), indicating that mediation was present. Full results of structural equation models can be seen in Table 3.

Mediation Model Results by Gender Possible gender differences in the mediation model were examined using a multiple-group analysis that compared a model that left structural weights free to vary across males and females with a model that constrained them to equality across gender. A significant decrease in model fit when constraining these parameters to be equal across gender provides evidence of moderation.32 The unconstrained model fit the data well (x2 D 30.61, df D 20, p < .10; CFI D .99, RMSEA D .03), as did the model that constrained the structural weights to equality across gender (x2 D 78.55, df D 35, p < .001; CFI D .95, RMSEA D .04). However, the constrained model provided a significantly worse fit to the data (Dx2 D 47.97, df D 15, p < .05), indicating that structural weights, measurement weights, and measurement intercepts were not equivalent across gender. Thus, moderation was present and the unconstrained model that allowed parameters to vary across gender will be further examined for mediation. For males, stress (b D .61, p < .001) and weight-related issues (b D ¡.19, p < .05) both significantly predicted depressive symptoms. However, depressive symptoms did not predict suicidality (b D .01, nonsignificant [ns]), which

TABLE 2. Group Means and Standard Deviations of All Variables Total Variable Subjective experience of stress Stressor frequency Desire for weight change Weight loss attempts Self-described weight Depressive symptoms—no suicide Suicidality

Male

Female

M

SD

M

SD

M

SD

3.60 1.25 .636 1.16 3.37 2.88 .052

.823 .232 .481 .935 .722 .965 .222

3.50 1.21 .605 .975 3.33 2.76 .041

.874 .226 .490 .885 .763 1.03 .200

3.66 1.27** .654 1.27** 3.39 2.94 .058

.787 .234 .476 .949 .697 .926 .234

**

Significant at the .01 level (2-tailed).

6

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Effects of Stress, Weight Issues, and Depression on Suicidality

FIGURE 1. Integrative mediation model demonstrating all pathways between study variables and testing depressive symptoms as mediating the relations between the latent constructs of stress and weight-related issues and suicidality.

TABLE 3. Parameter Estimates for Structural Equation Models for the Total Sample and Females and Males Total sample Path Self-described weight ! Weight issues Weight change desires ! Weight issues Weight loss attempts ! Weight issues Total stress ! Stress Stress count ! Stress Stress ! Depression Stress ! Suicide Weight ! Depression Weight ! Suicide Depression ! Suicide

b

Females SE

**

.53 .70*** .68*** .72*** .58** .64*** .45** ¡.09 ¡.09 ¡.13*

.11 — .17 — .24 .36 .11 .13 .03 .01

b

Males SE

***

.99 .91*** .49*** .69*** .57*** .65*** .48*** ¡.05 ¡.01 ¡.20*

.03 — .06 — .31 .45 .16 .06 .02 .02

b

SE ***

1.18 .75*** .39*** .73*** .60*** .58*** .31** ¡.16** .01 .01

.08 — .06 — .46 .55 .12 .06 .01 .01

Note. Standard errors could not be calculated for 2 of the manifest variables because they were used to standardize the latent variable.

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is inconsistent with mediation. General stress (b D .39, p < .01) and weight-related issues (b D ¡.19, p < .05) significantly predicted suicidality. Thus, for males, stress and weight had direct effects on suicidality that were not mediated through depressive symptoms, even though stress and weight-related issues both predicted depressive symptoms. Removing the mediation paths from this model resulted in a significant decrease in model fit (Dx2 D 70.72, df D 3, p < .001), indicating that these paths were needed to adequately account for the data despite the fact that not all of them were statistically significant. For females, stress (b D .65, p < .001), but not weightrelated issues, significantly predicted depressives symptoms and depressive symptoms significantly predicted suicidality (b D ¡.20, p < .05). General stress, but not weight-related issues, also had a direct effect on suicidality that was not mediated through depressive symptoms (b D .49, p < .001). Removing the mediation paths from this model resulted in a significant decrease in model fit (Dx2 D 145.67, df D 3, p < .001), indicating that these paths were needed to account adequately for the data, despite the fact that not all of them were statistically significant. COMMENT The current study examined depression as a mediator of the relationship between weight-related issues and suicidality, and between stress and suicidality. Given the prevalence of suicidal behavior in college students across the country and consistent research demonstrating significant associations between weight-related issues, stress, depression, and suicide, it is important to investigate comprehensive models that explain the relations between these constructs. Such a framework is well supported in the literature detailing the need to view such health-related issues through a holistic health lens.5 The mediation model in the current study provided supporting evidence that depressive symptoms mediate the relationship between stress and suicidality, as well as the relationship between weight-related issues and suicidality, for the total sample. Of note, stress was found to significantly predict suicidality, whereas weight-related issues did not exhibit a direct effect on suicidality. The current study also detected significant gender differences in the mediation model. Depressive symptoms did not mediate the relationship between stress and weightrelated issues and suicidality for males, whereas depressive symptoms did mediate the relationship between stress and suicidality for females. The current study serves to fill gaps in the literature on suicidal behavior in college students by expanding upon already published results. For instance, the current study demonstrated depression as a mediator of the relationship between stress and suicidality. Previous research provided evidence for the association between stress and depression, as well as the association between stress and suicidal behavior in college students, but few have focused on an overall holistic model linking all 3 factors. 8

The current results are consistent with findings highlighting depression and hopelessness as mediating factors between negative life events and suicidal ideation in college students.27,64,65 A step further, the present study adds the component of subjective experience of stress along with cumulative stressors to predict depression and suicidal behavior. Also, depression was found to mediate the relationship between weight-related issues and suicidality in this college sample. Similarly, past research has indicated that depression serves as a mediator between body image and alcohol problems, which then predicts suicidal behavior.37 Further, research has suggested that depression is a partial mediator of the association between the perception of being overweight and suicidal ideation.62 Given that depression was found to be a crucial step in the pathway to suicidality, it may be beneficial to investigate other factors associated with depression in college students. For example, it may be important to examine precursors to depression that may also result in suicidal behavior. In addition, this study demonstrated that cumulative stressors and subjective degree of stress experienced have a direct effect on suicidal behavior. This finding aligns with past research in young adults and US soldiers.49,50 This result adds to the literature by illustrating how the subjective experience of stressors, along with the amount of stressors experienced, significantly predicts suicidality in college students. Although studies have demonstrated these measures of stress as predictive of depression in college students,52,54,55 the current study expands upon this research to reveal the presence of direct associations with suicidal behavior in this population, which only increases the need to address the experience of substantial stress at an early stage. Gender differences emerged in models examined in the current study. Depressive symptoms did not mediate the relationship between stress or weight-related issues and suicidality for male college students. However, the study did exhibit mediating effects of depressive symptoms in the relationship between stress and suicidality for female college students. These findings partially align with the current and past literature. Results are consistent with previous research demonstrating how depression predicted suicidal ideation in females, but not in males.74 Further, results align with past research indicating the mediating role of depression in the relation between stress and suicidality in females.36 Mediation may not have been found in male participants due to specific mechanisms underlying the relationship between depression and suicidal behaviors in this population. Research has demonstrated the association between depression and suicidal behaviors to differ between males and females, such that there is a greater prevalence of depressive symptoms associated with suicidal behaviors in females than in males.79,80 Studies also suggest that young males may display more aggressive and impulsive behaviors leading to suicidal behavior, whereas young females demonstrate greater internalizing symptoms leading to suicidal behavior.80 JOURNAL OF AMERICAN COLLEGE HEALTH

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Further, the traditional male gender role, which discourages men from showing weakness or expressing emotion, can mask mental health symptoms associated with eventual suicidal behaviors, as men do not feel comfortable disclosing this information or seeking social or professional support.81 Therefore, depression may have a more pronounced association with various suicidal behaviors and thus operate as a stronger explanatory factor of suicidality in young adult females than in young adult males. Contrary to past research, weight-related issues were not significantly related to depression or suicidality in females. However, weight-related issues did predict both depression and suicidality in males in the current study. Inconsistent with our findings, previous research has indicated that both females and males who perceive themselves as overweight at age 14 experience mental health symptoms by age 21,60 and that females who engage in weight-loss practices have an inflated body weight perception as well as those who are overweight are more likely to report depressive symptoms than males.15,59,68 No study to the authors’ knowledge has indicated that males demonstrate significant associations between depression and weight-related concerns over and above females. However, one study found that underweight college men had greater problems functioning in social situations than that of overweight women,82 and research has indicated an increasing pressure to attain muscularity in males.83 In accordance, lower BMI has been linked with depressive symptoms and suicidal behavior in males.70 However, these particular weight concerns in males are not congruent with the endorsement of the current study’s measure of weight-related issues, as these issues focus on dissatisfaction with overweight status and a desire for weight loss rather than dissatisfaction with underweight status and desire for weight gain. Although the current study’s measure does not capture these aspects of weight-related concerns, the current study found weight-related issues to be related to both depression and suicidality in males, indicating that overweight concerns may be just as important as underweight concerns in males regarding mental health. Again, particular factors may be working to impede males from seeking help, which may be making associations between stress and weight-related issues and mental health symptoms more salient in males. One study highlighted how the desire to appear independent and to avoid appearing vulnerable were barriers to pursuing consultation for health issues for males,84 which may be contributing to the emergence of mental health symptoms that could have been otherwise prevented or treated upon taking advantage of helpful resources. Further, males have been found to be less likely to seek consultation for eating and weight-related concerns due to social and self-stigma surrounding ideals of masculinity.72,85,86 Overall, weight-related concerns and behaviors and their impact on psychological well-being may be more complicated in males; therefore, it is important to further investigate these associations, as the majority of the current literature VOL 63, JANUARY 2015

focuses on these associations in females. Future research should further explore and tease apart which specific aspects of weight-related concerns are most important when examining depression and suicidality separately by gender.

Limitations and Conclusions The current study also has several limitations. As the present study utilizes a cross-sectional design, the directional links between constructs cannot be assumed. Therefore, future research would benefit by examining these constructs longitudinally. Also, data from this study were collected from college students from 1 specific university. Future studies should aim to inspect these particular relations in other samples to determine if these results replicate as well as extend to a broader population. Although creating latent constructs has advantages, it is not clear whether certain aspects of weight-related issues or the general stress construct are especially contributing to outcomes. Thus, it may be beneficial to parse these constructs in future research to see if particular components are especially relevant in the pathways examined in the present study. Also, the measure created to assess suicidality in the current study included a question that may elicit the endorsement of experiencing nonsuicidal self-injury (NSSI), or deliberate self-harm behavior without the intention of death,87 as the item does not address whether the act is done with suicidal intention. Although NSSI is associated with suicide attempts, these behaviors are considered to be distinct regarding perception, intention, chronicity, function, and its potential risk and protective factors.87–91 For example, in a longitudinal study with college students, 1 in 6 students who reported engaging in NSSI had attempted suicide by the end of their college career.92 Thus, our suicidality measure may not be accurately capturing suicidal behavior in students. Future research should assess these constructs separately to examine how relations in the current study may differ as well as to provide a more precise measurement of suicidal behavior. Additionally, as negative life events have been found to interact with body dissatisfaction to predict depression in women, examining how particular stressors or the experience of stress may directly influence or exacerbate weightrelated issues in the prediction of depression and suicidality in college samples would be beneficial. Furthermore, given that only 21.9% of the participants responded and completed the survey, a sample bias may be present. Finally, as the sample was fairly homogenous in regards to race, future examinations of this kind should utilize a more racially diverse sample. Taking into consideration the holistic health framework, clinical implications of the present study suggest that colleges should focus on the all-inclusive early detection, screening, and treatment of depression, as it is a critical link between stressors and weight-related issues and 9

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suicidality in this population, particularly in females. Furthermore, emphasis should be placed on assessing perceived levels of stress in students and providing the necessary help to improve functioning and resiliency skills, as the experience of stress has the potential to lead to suicidal behavior in this population. Resources that allow students to gain holistic information and substantive assistance with stress as well as weight-related issues relevant to their particular gender should also be made available and accessible to students, as these factors have the potential to induce suicidal behavior differently in females and males. Overall, more research is needed to identify the mechanisms underlying the relations between stress, weight-related issues, depression, and suicidality in female and male college students so as to create more specialized, effective prevention and intervention programs aimed at promoting healthy lifestyles and to ultimately prevent devastating suicide outcomes.

FUNDING No funding was used to support this research and/or the preparation of the manuscript. CONFLICT OF INTEREST DISCLOSURE The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of DePaul University. NOTE For comments and further information, address correspondence to Sydney S. Smith, Department of Psychology, Barnwell College, University of South Carolina, Columbia, SC 209208, USA (e-mail: [email protected]). REFERENCES 1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at: http:// www.cdc.gov/injury/wisqars/index.html. Published 2010. Accessed July 22, 2013. 2. Wilcox HC, Arria AM, Caldeira KM, Vincent KB, Pinchevsky GM, O’Grady KE. Prevalence and predictors of persistent suicide ideation, plans, and attempts during college. J Affect Disord. 2010;127:287–294. 3. Turner JC, Leno EV, Keller A. Causes of mortality among American college students: a pilot study. J Coll Student Psychother. 2013;27:31–42. 4. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control: Definitions: Self-directed Violence. Available at: http://www.cdc.gov/violenceprevention/ suicide/definitions.html. Published 2012. Accessed July 22, 2013. 5. Guttmacher S. Whole in body, mind & spirit: holistic health and the limits of medicine. Hastings Center Rep. 1979;9 (2):15–16.

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on suicidal behavior in men. J Affect Disord. 2008;107: 37–43. 82. Harmatz MG, Gronendyke J, Thomas T. The underweight male: the unrecognized problem group of body image research. J Obes Weight Regul. 1985;4:258–267. 83. McCabe MP, Ricciardelli LA. Body image dissatisfaction among males across the lifespan: a review of past literature. J Psychosom Res. 2004;56:675–685. 84. Davies J, McCrae BP, Frank J, et al. Identifying male college students’ perceived health needs, barriers to seeking help, and recommendations to help men adopt healthier lifestyles. J Am Coll Health. 2000;48:259–267. 85. Gillon E. Can men talk about problems with weight? The therapeutic implications of a discourse analytic study. Couns Psychother Res. 2003;3:25–32. 86. Hackler AH, Vogel DL, Wade NG. Attitudes toward seeking professional help for an eating disorder: the role of stigma and anticipated outcomes. J Couns Dev. 2010;88:424–431. 87. Wilkinson P, Goodyer I. Non-suicidal self-injury. Eur Child Adolesc Psychiatry. 2011;20:103–108. 88. Andover MS, Morris BW, Wren A, Bruzzese ME. The cooccurrence of non-suicidal self-injury and attempted suicide among adolescents: distinguishing risk factors and psychosocial correlates. Child Adolesc Psychiatry Ment Health. 2012;6: 1–7. 89. Andover MS, Washburn JJ, Styer DM. Non-suicidal selfinjury. In: Grossman L, Walfish S, eds. Translating Psychological Research Into Practice. New York, NY: Springer Publishing; 2014:217–223. 90. Brausch AM, Gutierrez PM. Differences in non-suicidal self-injury and suicide attempts in adolescents. J Youth Adolesc. 2010;39:233–242. 91. Tuisku V, Kiviruusu O, Pelkonen M, Karlsson L, Strandholm T, Marttunen M. Depressed adolescents as young adults— predictors of suicide attempt and non-suicidal self-injury during an 8-year follow-up. J Affect Disord. 2014;152:313–319. 92. Wilcox HC, Arria AM, Caldeira KM, Vincent KB, Pinchevsky GM, O’Grady KE. Longitudinal predictors of past-year non-suicidal self-injury and motives among college students. Psychol Med. 2012;42:717–726. Received: 24 September 2013 Revised: 28 June 2014 Accepted: 10 August 2014

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