The Relationship Between the Suicide Crisis Syndrome and Suicidal Ideation in Adolescents: A Preliminary Validation Study Using Data from the Young-HUNT3 epidemiological study

The Relationship Between the Suicide Crisis Syndrome and Suicidal Ideation in Adolescents: A Preliminary Validation Study Using Data from the Young-HUNT3 epidemiological study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Relationship Between the Suicide Crisis Syndrome and Suicidal Ideation in Adolescents: A Preliminary Validation Study Using Data from the Young-HUNT3 epidemiological study Lisa J. Cohen, Tingting Feng, Arne E. Vaaler, Zimri Yaseen, Sarah Bloch ElKouby, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9473762/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Suicide among youth has increased over past decades and is now among the most common causes of death for adolesecents. Suicidal ideation, the traditional basis of risk assessment, has serious limitations in predicting imminent risk, necessitating novel modes of risk assessment. The Suicide Crisis Syndrome (SCS) is an acute cognitive-affective state that has been shown to be predictive of near-term suicidal thoughts and behavior. It is currently under consideration for inclusion in DSM as a suicide-specific disorder. To date, the SCS has not been tested in adolescents. The present study examines the concurrent validity of the SCS with regard to suicidal ideation using data from an epidemiological study of adolecent health, the Norwegian Young-HUNT3 study. Methods The sample included 8,199 adolescents, aged 13–20, who participated in the Young HUNT3 study, administered between 2006 and 2008 in the Trøndelag district of Norway. Of these, 3,212 respondents answered a question on history of suicidal ideation. The SCS was assessed by a proxy measure (SCS-YHP) derived from the survey items. The association between the SCS-YHP and suicidal ideation was assessed through several logistic regression analyses. Sensitivity analyses were performed to test two additional formats of the SCS-YHP, maintaining the same items but reducing the stringency of the criteria to increase the case rate. Results Concurrent validity was strong for all three formats. Odds ratios ranged from 6.72 to 11.75 and were significant, at minimum, at the .002 level, such that adolescents who were rated as SCS positive, by any of 3 different formats, were approximately 7–12 times more likely to report a history of suicidal ideation. These associations remained significant after controlling for age and sex. Sensitivity and specificity were also high; 67 to 78% for sensitivity and 77–78% for specificity across the three formats, the most stringent format having the strongest sensitivity/specificity. Conclusions As an important first step, this study provides prelmimary evidence of concurrent validity for the Suicide Crisis Syndrome among adolescents. Future research can aim to replicate these findings with a validated measure of the SCS for youth and to test predictive validity to suicidal behavior. Suicide risk assessment Suicide Crisis Syndrome HUNT study adolescents suicidal ideation Background Suicide is one of the main causes of death globally. In 2021, an estimated 727,000 people died by suicide [ 1 ], more than died by breast cancer, war, homicide, HIV/AIDS or malaria. Suicide is a particularly serious problem among youth and was the 4th most common cause of death among people aged 15–19 worldwide in 2021. Although the rate of youth suicide is higher among males than females [ 2 ], at a ratio of about 5 to 2 [ 3 ], suicide is the 2nd most common cause of death for females in this age group [ 1 ]. In recent decades, the rate of youth suicide has increased in several countries, including the United States, United Kingdom, Australia, and Canada [ 4 ]. Likewise, suicide rates among youth aged 10–24 rose from 1980 to 2020 in North America, Central-South America, and Asia-Oceania [ 3 ]. Clearly, youth suicide is a pressing public health problem requiring effective preventative strategies. Suicidal behavior in adolescents may differ from that in adults in a number of dimensions. Adolescents tend to be more impulsive and affectively reactive than adults [ 5 – 7 ]. Likewise, they are more sensitive to interpersonal difficulties, which serve as a major trigger for suicidal behavior [ 8 ]. In a comparison of adult and adolescent psychiatric admissions following suicidal ideation or behavior, Parellada and colleagues [ 9 ] found that adolescents tended to use less lethal methods, were more uncertain in their intent and engaged in more impulsive behavior [ 9 ]. In a 2018 review by Steele and colleagues, adolescent risk factors for suicides and suicidal behaviors included insomnia, perceived burdensomeness, bullying, school problems, and recent conflict with a family or a romantic partner. In contrast, risk factors for adults included being male, substance abuse, low education, occupational, financial or legal distress and being single, divorced or widowed. Psychiatric illness, particularly depression, and prior suicide attempts crossed generational boundaries [ 10 ]. Cyber bullying, in particular, has received more attention of late, and may be particularly damaging to adolescent girls [ 2 , 9 ]. Likewise, social media has come to play an increasingly dominant role in adolescents’ lives and more frequent use has been linked to poorer mental health and suicidal ideation [ 2 , 11 , 12 ]. Possible mechanisms include sleep interference, distraction from other activities, negative social comparisons, perceived peer exclusion and cyber bullying. Traditionally, suicide risk assessment has relied almost exclusively on self-reported suicidal ideation (SI) [ 13 ], which poses numerous challenges [ 14 – 16 ]. Suicidal individuals may choose not to disclose SI [ 17 ], often to avoid hospitalization, embarrassment, or feared judgment [ 18 ]. Likewise, SI is highly variable and can fluctuate dramatically throughout the day [ 19 ]. In studies by Deisenhammer and colleagues [ 20 ] and Paashaus and colleagues [ 21 ], more than 40% of study participants reported less than 10 minutes between the onset of SI and suicidal action. This time frame might be even shorter among adolescents given their elevated impulsivity. In response to these limitations, increasing attention in recent years has been directed to the concept of a suicidal mental state. The Suicide Crisis Syndrome (SCS), in particular, has been extensively researched. The SCS has shown robust associations with near-term suicidal behavior (See [ 22 , 23 ] for reviews) and is currently under consideration for inclusion in the Diagnostic and Statistical Manual for Psychiatric Disorders (DSM-5-TR) [ 24 ]. The SCS describes a hyperaroused, negative affective-cognitive state characterized by a profound sense of entrapment. Fifteen symptoms are categorized into 5 criteria that together comprise a unified construct [ 25 ]. Criterion A is Entrapment, defined as an overpowering sense of being trapped in an intolerable and inescapable situation. Criterion B, Associated Features, has four subcriteria. Criterion B1, Affective Distress, refers to acute and severe emotional distress, psychological pain or mood lability. Criterion B2, Disturbances in Arousal, refers to a hyperaroused and agitated state characterized by hypervigilance, extreme tension or insomnia. Criterion B3, Loss of Cognitive Control, refers to a profusion of negative thoughts, overwhelming rumination and the inability to shift attention or think flexibly. Criterion B4, Acute Social Withdrawal, refers to a recent and abrupt withdrawal from social connections and/or evasive communication. Individuals meet criteria for SCS if they score positively on at least one symptom from all 5 domains [ 26 ]. To date, all studies published on the SCS have been conducted with adult populations. Across multiple independent samples, confirmatory factor analyses have shown SCS to be a coherent, unitary construct with five separate subdomains [ 27 – 29 ]. Within both clinical and community adult samples, the SCS was found to predict near-term suicidal ideation and behavior [ 27 , 30 ] and did so over and above traditional risk factors such as depressive symptoms and suicidal ideation [ 27 , 31 ]. A measure of the SCS was also shown to predict long term risk of suicide death 1 . Further, discriminant validity over depression, obsessive compulsive disorder, personality and posttraumatic stress disorders have also been demonstrated [ 32 ]. Moreover, measures of the SCS have been adapted and implemented into standard clinical procedures in psychiatric settings in the United States [ 33 , 34 ] and Hungary [ 35 ], where they have demonstrated high clinical utility with regard to clinical decision making [ 33 ]. Because of adolescents’ unique developmental challenges, exclusive reliance on suicidal ideation for risk assessment might be even more problematic than with adults. Adolescents are known to be more impulsive and emotionally reactive even than younger children and are often reluctant to confide in adults [ 5 , 36 ]. As such, assessment of an acute negative affect state may be of heightened clinical utility in suicide prevention. Moreover, such a state may be more easily detected by parents, teachers, friends and other family members, allowing for more timely interventions, even when adolescents are reluctant to self-disclose SI. Likewise, adolescents themselves can be educated to recognize these symptoms and to seek out support before they escalate to a dangerous level. Currently, there are no published studies of SCS in adolescents although an Israeli study of 335 adolescents presenting to the emergency room has been completed and publicly presented 2 . Of note, the Barzilay study assesses a clinical population, such that SCS remains untested in the general adolescent population. The present study assesses the relationship between SCS symptoms and history of suicidal ideation in a sample of 3,195 adolescents surveyed in the Young-HUNT3 epidemiological study from the Trøndelag district of Norway. Although, as noted above, SI is a problematic marker of imminent risk of suicide, it is still a worthwhile target of study. It is indicative in and of itself of a high level of distress and the risk of either suicidal attempt or death by suicide is meaningfully higher in people with suicidal ideation than without [ 37 – 39 ]. Specifically, in an epidemiological study of 6,483 adolescents in the United States, one third of the participants with SI later attempted suicide [ 40 ]. Moreover, as a preliminary step, it is critical to link SCS among adolescents with an established marker of suicidal risk. The HUNT studies are designed to provide a comprehensive picture of public health in the Norwegian district of Trøndelag and include a section on mental health. Young-HUNT3 was aimed at adolescents aged 13 to 20 and conducted between 2006 and 2008. Although Young-HUNT3 did not include a validated measure of SCS, items from the mental health section of the survey were extracted to create a proxy measure of SCS, a research design which has been utilized previously [ 26 ]. Likewise, across many fields of study, proxy or derived measures are frequently used with epidemiological data when the phenomenon of interest was not addressed in the original research design [ 41 – 43 ]. Of note, this study serves as a companion study to an initial SCS-HUNT study, testing the predictive validity of a proxy measure of SCS in adults to deliberate self-harm and death by suicide 1 . The hypotheses tested in this study are: Adolescents who meet criteria for SCS will have reported an increased rate of lifetime suicidal ideation, with high levels of sensitivity and specificity. SCS will show incremental concurrent validity for suicidal ideation, after controlling for age and sex, two characteristics previously associated with suicidal risk [ 1 , 3 ]. Suicidal ideation will be independently associated with each of the 5 SCS criteria after controlling for intercorrelations. To the extent these hypotheses are supported, this will provide an important first step in demonstrating construct validity for the SCS in adolescents. Methods Collaboration This study was conducted as part of a collaboration between a research team at the Icahn School of Medicine at Mount Sinai in New York City and researchers at the Norwegian University of Science and Technology (NTNU) in Trondheim, Norway. A collaboration agreement between the two institutions specified the scope of work and the procedures for data sharing. The project was approved by the Regional Committee for Medical and Health Research Ethics – Southeast Norway (ref. 2018/1037). Source of Data The Trøndelag Health Study (Helseundersokelsen i Trøndelag: HUNT) is a population-wide survey on health and health behaviors sent to all residents of Trøndelag County in Norway. HUNT is a collaboration between HUNT Research Centre (Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU), Trøndelag County Council, Central Norway Regional Health Authority, and the Norwegian Institute of Public Health. HUNT3 was the third of a series starting in 1984 and took place between October, 2006 and June, 2008. Young-HUNT3 was the adolescent component of HUNT3. Recruitment took place largely through junior high and high schools. After the principal of each of the 66 schools in the district gave written consent for the school’s participation, invitation letters were sent to all students and their parents or guardians describing the study and use of data. All participants and parents of those under age 16 provided written informed consent. For all participating students, an anonymized questionnaire was administered in a school classroom in an “exam-like setting.” Approximately one month later, a nurse visited the school for follow-up interviews and physical measurements. Data for this study was drawn solely from the questionnaire. Adolescents not in school were contacted by mail and invited to complete the questionnaire and to attend an adult screening site. Young-HUNT was approved by the Norwegian Data Inspectorate, the Regional and National Committees for Medical and Health Research Ethics and the Norwegian Directorate of Health. See [ 44 ] for a detailed description of the Young-HUNT studies. Participants Of the 10,464 adolescents invited to participate in the Young-HUNT3 study, 5,614 (53.7%) were in junior high school, 4,357 (41,6%) were in high school, and 493 (4.7%) were not in school. Of those invited, 8,200 (78.4%) completed the questionnaire. The response rate was 84.6% for junior high students, 76.6% for high school students, and 23.3% for adolescents not in school [ 44 ]. Measures Proxy SCS measure (SCS-YHP) Items for the proxy Young-HUNT3 SCS (SCS-YHP) were extracted from the baseline questionnaire, which incorporated items from multiple sources. Items for Criteria A, B1, B2 and B3a were drawn from the 5-item Hopkins Symptoms Checklist (HSCL-5), a widely used, 5-item questionnaire measuring emotional distress [ 45 ]. Additional items assessing social isolation and insomnia (Criteria B3b and B4) were extracted from questionnaires designed by the Norwegian Institute of Public Health. See Table 1 for description of the items and scoring criteria. Table 1 Scoring Criteria for the SCS Proxy Measures Note . SCS YHP = Suicide crisis Syndrome Young-HUNT Proxy. Variables in the HUNT study can be reviewed at the following link: https://hunt-db.medisin.ntnu.no/hunt-db/variablelist SCS Criteria Data Source HUNT Variables Coding Scheme Criterion A: Entrapment Hopkins Symptom Checklist (SCL-5) Last 14 days felt hopelessness when you think of the future? 4 = Very bothered Criterion B1: Affective Disturbance Hopkins Symptom Checklist (SCL-5) B1b or B1c Criterion B1b: Depressive Turmoil Hopkins Symptom Checklist (SCL-5) Last 14 days felt dejected or sad? 4 = Very bothered Criterion B1c: Extreme Anxiety Hopkins Symptom Checklist (SCL-5) Last 14 days been constantly afraid and anxious? 4 = Very bothered Criterion B2: Loss of Cognitive Control Hopkins Symptom Checklist (SCL-5) Last 14 days worried too much about various things? 4 = Very bothered Criterion B3: Hyperarousal B3a or B3b Criterion B3a: Agitation Hopkins Symptom Checklist (SCL-5) Last 14 days felt tense or uneasy? 4 = Very bothered Criterion B3b: Global Insomnia Norwegian Institute of Public Health Last month had difficulty falling asleep in the evening? 1 = Almost every night Criterion B3b: Global Insomnia Norwegian Institute of Public Health Last month woke too early and couldn’t fall asleep again? 1 = Almost every night Criterion B4: Acute Social Withdrawal Norwegian Institute of Public Health Any of the items below are positive Norwegian Institute of Public Health How many close friends? Those you can confide in and who help you when you need help. 1 = None or one Norwegian Institute of Public Health How often have you visited someone you know? 1 = None Norwegian Institute of Public Health How often have you gone out with friends more than two hours in a row? 1 = None Criterion A3: Entrapment modified Last 14 days felt hopelessness when you think of the future? 3 = quite bothered or 4 = very bothered Criterion B1.3: Affective Disturbance modified Last 14 days been constantly afraid and anxious? 3 = quite bothered or 4 = very bothered or B1b SCS-YHP 1 Calculated Scores See above SCS A, B1, B2, B3 and B4 SCS-YHP 2 Calculated Scores See above SCS A and B1, B2, B3 or B4 SCS-YHP 3 Calculated Scores See above SCS A3, B1.3, B2, B3, and B4 Note . SCS YHP = Suicide crisis Syndrome Young-HUNT Proxy. Variables in the HUNT study can be reviewed at the following link: https://hunt-db.medisin.ntnu.no/hunt-db/variablelist SCS-YHP is a binary variable marking the presence or absence of SCS. In keeping with previously established criteria for the proposed DSM diagnosis [ 22 , 32 ], participants with at least one symptom in each domain were rated to meet criteria for that domain. The number of domains required for the final binary rating of SCS varied, however, as is detailed below. Initially, the SCS-YHP was designed theoretically, based on face validity. As there were no means of measuring criterion validity within the Young-HUNT3 dataset, we developed two alternative versions to provide sensitivity analyses of the relationship between SCS and suicidal ideation. SCS-YHP 1. This first measure was the most stringent. In accord with the proposed DSM SCS criteria, a positive rating on all 5 criteria was required for a positive SCS diagnosis. SCS-YHP 2. Because of the small percent of study participants scoring positively using SCS-YHP 1 (N = 19, 0.24%), a less stringent measure was designed, requiring only Criterion A plus any of Criteria B1-B4 to be positive. Although these criteria differ from the proposed DSM SCS diagnostic criteria, a similar metric has been successfully used clinically in hospital systems in Chicago, Illinois [ 33 , 34 ] and Pecs, Hungary [ 35 ]. Further, prior studies have demonstrated predictive validity with different combinations of the 5 SCS criteria [ 27 ]. In all such cases, however, Entrapment/Frantic Hopelessness (Criterion A) is required. SCS-YHP 3. To maintain consistency with the proposed DSM SCS diagnosis but still relax inclusion criteria, a second alternative scoring system was designed. SCS-YHP 3 maintained the requirement of all 5 SCS criteria but loosened the criteria for Criterion A and Criterion B1 (See Table 1 ). [INSERT Table 1 HERE] Suicidal Ideation Suicidal ideation was assessed with the question: Have you ever had thoughts of taking your own life? History of suicidal behavior (e.g., attempts, gestures) was not assessed in Young-HUNT3 so could not be assessed in this study. Demographic and clinical characteristics Information on age, sex, and impairment due to mental health problems (coded no, a little, somewhat or severely) was also extracted from the baseline questionnaire. In Young-HUNT3, sex was coded only as male vs. female. Data Analysis Initial analyses provided descriptive data to characterize the SCS results in this sample. To test concurrent validity in Hypothesis 1, logistic regression regressed suicidal ideation on SCS-YHP. Sensitivity and specificity were also assessed. To test incremental validity in Hypotheses 2, age and sex were added to the models. Due to the low case rate for all three models, positive and negative predictive values were not calculated as they are dependent on prevalence within the population [ 46 ]. To test the independent validity of each domain in Hypothesis 3, SI was regressed against all five domain scores. Given the potential for heteroscedasticity in the data, we utilized robust standard errors to enhance the reliability of our estimates. For sensitivity analyses, all hypotheses were tested using all three SCS-HP formats. Missing data was handled listwise; only records with complete data were included in each analysis. To preserve power given the low case rate, we elected to include all available data in each analysis even though sample size varied depending on the variables included. All data was analyzed with STATA v. 180/MP. The AI platform POE was used solely to help format commands for data analysis in STATA. Results The entire sample used for analysis included 8,199 participants. Of these, 8,041 had sufficient data for SCS-HYP 1; 19 participants (0.23%) rated SCS positive and 8,022 (97.8%) rated negative. With the more inclusive SCS-YHP 2, there was, as expected, a larger case rate (N = 176, 2.21% of 7,979). The final model, SCS-YHP 3, yielded 25 cases (0.31% of 8,039). Although not consistent across SCS-YHP formats, participants meeting criteria for SCS were younger than their non-SCS counterparts and more likely to be females than males. Across all 3 formats, participants meeting criteria for SCS reported dramatically higher rates of impairment due to a mental health condition, at least 20 times more likely to rate high/severe impairment vs. no/a little. See Table 2 . Table 2 Demographic and Clinical Features in Relation to SCS SCS Format SCS No SCS Statistic p value Effect Size SCS-YHP 1 (N = 8,041) 19 (0.23%) 8,022 (99.8%) --- --- Sex c 2 (1) = 4.05 .044 OR = 2.74, 95% CI: 0.99, 7.6 Female 14 (%) 4,056 (%) --- --- *Fisher’s exact = 0.06, p > .05 Male 5 (%) 3,966 (%) --- --- Age: mean (sd) 16.71 ± 1.67 15.88 ± 1.74 t(8,039)= -2.07 .039 Cohen’s d = 0.49 Impairment c 2 (1) = 131.91 < .00001 OR = 31.82, 95% CI: 12.6, 80.29 No, a little 162 (2.23%) 7,089 (88.6%) --- --- Somewhat/ severely 8 (42.1%) 11 (57.9%) --- --- SCS-YHP 2 (N = 7,977) 176 (2.21%) 7801 (97.8%) --- --- Sex c 2 (1) = 23.53 0.001 OR = 2.17, 95% CI: 1.60, 3.00 Female 121 (2.99%) 3922 (97.0%) --- --- Male 55 (1.40%) 3881 (98.6) --- --- Age: mean (sd) 16.47 ± 1.69 15.87 ± 1.74 t [7,977] = -4.49 < .001 Cohen’s d = 0.35 Impairment c 2 (1) = 456.68 < .00001 OR = 20.8, 95% CI: 14.2, 30.7 No, a little 125 (1.77%) 6,939 (98.2%) --- --- Somewhat/severely 45 (27.3%) 120 (72.7%) --- --- SCS-YHP 3 (N = 8039) 25 (0.31%) 8,014 (99.69%) --- --- Sex c 2 (1) = 6.46 0.011 OR = 3.11, 95% CI: 1.24, 7.71 Female 19 (0.47%) 4,051 (99.53%) --- --- Fisher’s exact = 0.147, p<.05 Male 6 (0.15%) 3,963 (99.85%) --- --- Age: mean (sd) 16.38 ± 1.81 15.88 ± 1.74 t (8037) = -1.43 0.15 Cohen’s d = 0.28 Impairment c 2 (1) = 130.32 < .00001 OR = 26.4, 95% CI: 11.4, 61.3 No, a little 15 (0.02%) 7,083 (99.79%) --- --- Somewhat/ severely 9 (5.29%) 161 (94.70%) --- --- Note . SCS YHP = Suicide crisis Syndrome Young-HUNT Proxy. OR= Odds Ratio. *Fisher’s exact test provided [by socsci] when cell size is 6 or under. (Cohen’s d first checked on POE and then validated on socscIstatistics.com/effectsize/default3.aspx OR’s provided by POE [INSERT Table 2 HERE] Concurrent Validity (Hypothesis 1) Reported history of suicidal ideation was remarkably common in this sample. Almost a quarter (N = 743, 23%) of the participants who answered the question (N = 3,212) reported a history of suicidal ideation. Concurrent validity was strong for all three formats, as presented in Table 3 . Odds ratios ranged from 6.72 to 11.75 and were significant, at minimum, at the .002 level. This suggests that adolescents who were rated as SCS positive, by any of 3 different formats, were approximately 7–12 times more likely to report a history of suicidal ideation. Of note the highest odds ratio was achieved for the most stringent model (SCS-YHP 1) although this difference between models was not significant, as indicated by the overlapping 95% confidence intervals. Sensitivity and specificity for each format were as follows: 77.8% and 77.0% for SCS-YHP 1; 67.0% and 78.3% for SCS-YHP 2; and 66.7% and 77.1% for SCS-YHP 3. Table 3 Prediction to Suicidal Thoughts of the Three SCS formats: Logistic Regression Analyses SCS Format SI No SI OR 95%LLCI 95%ULCI p value SCS-YHP 1 7 (78%) 2 (22%) 11.75 2.44 56.71 .002 No SCS-YHP 1 (ref.) 731 (23%) 2,455 (77%) SCS-YHP 2 61 (67%) 30 (33%) 7.35 4.71 11.48 < .001 No SCS-YHP 2 (ref.) 666 (22%) 2,408 (78%) SCS-YHP 3 8 (67%) 4 (33%) 6.72 2.02 22.39 .002 No SCS-YHP 3 (ref.) 730 (23%) 2,453 (77%) Note . SCS = Suicide Crisis Syndrome. SCS 1 requires all 5 criteria to be present, which parallels the proposed DSM diagnosis but generated a minimal cell size. SCS 2 requires Criterion A to be present plus one of Criteria B1-B4. This is less stringent but generates a larger cell size (N = 91 in this analysis). SCS3 requires all 5 SCS criteria be met as with SCS 1 but relaxes the requirements for Criteria A and B1. Incremental Validity (Hypothesis 2) For each format, concurrent validity held strong when age and sex were entered into the models. Adjusted odds ratios for the SCS ranged from 6.13 to 10.59. Although female sex was a significant risk factor in the three models, age was not. In this case too, the SCS-YHP1 achieved the highest odds ratio but the difference was not significant. (See Table 4 ). Table 4 Incremental Validity to Suicidal Ideation of Each SCS Format Controlled for Age and Sex SCS Format SI No SI OR 95%LLCI 95%ULCI p value SCS-YHP 1 (N = 3,195) SCS 1 7 (78%) 2 (22%) 10.59 2.15 52.13 .004 No SCS 1 (ref.) 731 (23%) 2,455 (77%) Male 311 (20%) 1,228 (80%) 0.73 0.62 0.86 < .001 Female (ref.) 432 (26%) 1,241 (74%) Age: mean (sd) 17.61 (0.9) 17.63 (0.9) 0.97 0.88 1.06 .472 SCS-YHP 2 (N = 3,165) SCS 2 61 (67%) 30 (33%) 7.09 4.51 11.14 < .001 No SCS 2 (ref.) 666 (22%) 2,408 (78%) Male 311 (20%) 1,228 (80%) 0.75 0.63 0.89 .001 Female (ref.) 432 (26%) 1,241 (74%) Age: mean (sd) 17.61 (0.9) 17.63 (0.9) 0.96 0.87 1.05 .385 SCS-YHP 3 (N = 3,195) SCS 3 8 (67%) 4 (33%) 6.13 1.84 20.37 .003 No SCS 3 (ref.) 730 (23%) 2,453 (77%) Male 311 (20%) 1,228 (80%) 0.73 0.62 0.86 < .001 Female (ref.) 432 (26%) 1,241 (74%) Age: mean (sd) 17.61 (0.9) 17.63 (0.9) 0.97 0.88 1.06 .492 Note . SCS = Suicide Crisis Syndrome. SI= Suicidal Ideation. OR= Odds Ratio. SCS 1 requires all 5 criteria to be present, which parallels the proposed DSM diagnosis but generated a minimal cell size. SCS 2 requires Criterion A to be present plus one of Criteria B1-B4. This is less stringent but generates a larger cell size (N = 91 in this analysis). SCS3 requires all 5 SCS criteria be met as with SCS 1 but relaxes the requirements for Criteria A and B1. Independent validity of Each SCS Criterion (Hypothesis 3) To test the independent relationships between the 5 SCS criteria and history of suicidal thoughts, two analyses were run, the first with the original 5 criteria and the second replacing Criteria A and B1 with the less stringent versions of these criteria used in SCS-YHP 3. In the first more stringent model, each SCS criterion was independently associated with suicidal thoughts. In the second model, all but B4, acute social withdrawal, were independently associated with suicidal thoughts. (See Table 5 ). Table 5 Independent Contributions of Each SCS criterion to Prediction of Concurrent Suicidal Thoughts SCS Criterion SI N (%) No SI N (%) AOR 95%ULCI 95%LLCI p value Model 1 (N = 3070) SCS A 74 (62.2) 45 (37.8) 2.44 1.48 4.00 < .001 No SCS A (ref) 654 (21.4) 2,395 (78.6) SCS B1 94 (72.9) 35 (27.1) 3.87 2.39 6.25 < .001 No SCS B1 (ref) 629 (20.8) 2,397 (79.2) SCS B2 136 (59.1) 94 (40.9) 2.88 2.03 4.07 < .001 No SCS B2 (ref) 588 (20.0) 2349 (80.0) SCS B3 111 (48.7) 117 (51.3) 1.77 1.27 2.47 .001 No SCS B3 (ref) 605 (20.9) 2287 (79.1) SCS B4 148 (29.6) 352 (70.4) 1.31 1.03 1.65 .025 No SCS B4 (ref) 578 (21.9) 2063 (78.1) Model 2 (N = 3071) SI N (%) No SI N (%) AOR 95%ULCI 95%LLCI p value *SCS3 A 209 (51.0) 201 (49.0) 2.66 2.06 3.44 < .001 No SCS3 A (ref) 519 (18.8) 2239 (81.2) *SCS3 B1 137 (64.9) 74 (35.1) 3.22 2.22 4.66 < .001 No SCS3 B1 (ref) 587 (19.9) 2358 (80.1) SCS B2 136 (59.1) 94 (40.9) 2.21 1.54 3.18 < .001 No SCS B2 (ref) 588 (20.0) 2349 (80.0) SCS B3 111 (48.7) 117 (51.3) 1.64 1.16 2.30 .005 No SCS B3 (ref) 605 (20.9) 2287 (79.1) SCS B4 148 (29.6) 352 (70.4) 1.24 0.98 1.58 .074 No SCS B4 (ref) 578 (21.9) 2063 (78.1) Note . SCS = Suicide Crisis Syndrome, AOR = adjusted odds ratio, LLCI = lower limit confidence interval, ULCI = upper limit confidence interval, *alternative, less stringent formats for Criteria SCS A and SCS B1 entered into Model 2 with the other SCS criteria. Discussion The primary aim of this paper was to provide initial validation of the Suicide Crisis Syndrome in adolescents, specifically in a community population. We hypothesized that a proxy measure of the SCS extracted from the epidemiological Young-HUNT3 study would be associated with a history of suicidal ideation in youth aged 13–20, that this relationship would have high sensitivity and specificity, and that it would be sustained after controlling for age and sex. Additionally, we hypothesized that each SCS domain would be independently associated with suicidal ideation. Indeed, in all three SCS formats, our hypotheses were supported, with the exception of SCS Criterion B4 in the analysis of SCS-YHP 3. This is, to our knowledge, one of the first studies showing construct validity for SCS in adolescents and the first within the general population. We believe that SCS can provide a valuable addition to suicide prevention in adolescents, who are often reluctant to disclose suicidal ideation to adults. Moreover, adolescents exhibit greater emotional reactivity and impulsivity than adults [ 6 , 7 ], which serve as strong drivers of suicidal behavior in this age group [ 8 ]. SCS, a hyper-aroused, negative affect state, characterized by loss of cognitive control, precisely focuses on an emotionally dysregulated mental state strongly associated with suicidal thoughts and behavior [ 22 , 23 ]. To the extent that family, friends, clinicians, teachers and adolescents themselves are educated about SCS, this can potentially provide a valuable early warning system for suicidal risk, flagging the possible need for intervention and support. Future research can demonstrate whether the clinical utility of SCS already documented in adults [ 33 , 34 ] can generalize to adolescents. Future research can also investigate treatment options for SCS as a stand-alone syndrome. In all three formats, the SCS-YHP showed relatively strong sensitivity and specificity. Sensitivity is arguably most important in risk assessment, such that people at risk are flagged and not overlooked. Lower specificity can be mitigated by treating the measure as an initial screen, identifying the need for further evaluation. Nonetheless, our specificity was also high, which is not always the case with suicide risk protocols [ 47 , 48 ]. At this stage, the incidence of SCS in adolescence is not known. Incidence in community populations of adults has ranged from 3.6% to 16.2% across countries [ 49 ]. However, the reliance on self-selected samples in the online surveys used to collect these data may overestimate the incidence in the population while the use of proxy measures, such as the one in the current study and in the adult HUNT3 study 1 , likely underestimates the incidence. Importantly, in this epidemiological study, 23% of survey respondents who answered the question reported a history of suicidal ideation. Even if the 60% of survey participants with missing data denied history of SI, that would still indicate prior or current SI in at least 9.2% of this community population of adolescents. According to the Anne E. Casey Foundation [ 50 ], in 2022–2023 in the United States, an estimated 18% of adolescents had at least one major depressive episode in the past year, while 20% reported symptoms of anxiety and 31% had a mental, emotional, developmental or behavioral problem. Given these statistics, it is highly likely that the actual incidence of SCS is higher than found in this study. SCS was strongly associated with self-reported severe mental health impairment, with odds ratios consistently above 20. This supports the notion of SCS as a stand-alone psychiatric disorder, associated with distress and dysfunction even outside of its relation to suicide risk. We also found that older adolescents and females vs. males were more likely to meet criteria for SCS on the SCS-YHP, although this was not consistent across SCS-YHP formats. That females report a higher incidence of SCS than males is consistent with robust findings in the literature of greater incidence of depression, suicidal ideation and other internalizing disorders in girls and women [3. 51] The extent to which this reflects a true difference in prevalence rather than self-disclosure remains unclear [ 15 , 52 ] but it has also been shown that males are more likely to manifest emotional distress in externalizing disorders, that is in action rather than in subjective experience [ 53 , 54 ]. In this regard, clinician ratings might offer advantages over self-report questionnaires. In adult samples, SCS has been more common in younger people [ 49 ], which is not consistent with the present findings. The younger age of participants without SCS may reflect the presence of pubertal or pre-pubertal adolescents who may not have fully encountered the challenges of adolescence, a consistent finding among youth studies [ 51 ]. That the participation rate was highest (86%) among junior high students, who required parental consent, also suggests a possible self-selection bias towards greater health concerns in older students who elected to participate in the HUNT survey. Limitations The findings of this study should be considered in the context of its limitations. For one, SCS was measured with a proxy measure extracted from the Young-HUNT3 study, which has not been validated against other validated SCS measures. While this proxy measure lacked evidence of criterion validity, that is convergent validity with published and validated measures of the SCS, its association with SI, as demonstrated across multiple formats, provides preliminary indication of construct validity. Likewise, proxy measures have frequently been derived from epidemiological data that did not include the measures of interest in its original design. This has been done across multiple fields, including suicide research and mental health [ 41 – 43 ]. Future research should replicate the current findings with validated SCS measures, such as the Suicide Crisis Inventory, 2nd edition (SCI-2) [ 27 ], the SCS-Checklist (SCS-C) [ 22 ], the SCI-short form (SCI-SF) [ 55 , 56 ], or the Abbreviated SCS-C (A-SCS-C) [ 33 , 34 ]. The Youth Suicide Crisis Inventory (Y-SCI) from the Barzilay group shows particular promise for adolescents 2 . Additionally, although the use of an epidemiological study enhanced generalizability, the pattern of missing data introduced the possible confound of self-selection bias. Moreover, the findings may not generalize to other countries and cultures. Nonetheless, SCS in adults has shown remarkable consistency across cultures, for example, in Russia [ 57 ], Brazil [ 58 ], and Korea [ 28 ]. Further, these findings, which are based upon data from 2006 to 2008, may not generalize to the present time, where social media plays such a central role in adolescent lives. This might both amplify pre-existing suicidal risk factors (e.g., sleep disturbance) and introduce new ones (e.g., cyberbullying) [ 59 ]. Nonetheless, we can speculate that these new circumstances might heighten the relevance of SCS among adolescents. Finally, this study did not measure the association with or prediction of suicidal behavior, gestures or death by suicide. Rather it measured lifetime SI. As noted above, while SI is far less dangerous than either suicidal behavior or death by suicide, and the characteristics of individuals with SB and who die by suicide vary to some extent [ 60 ], SI is nonetheless an established and widely used measure of suicidal risk [ 13 ] and a meaningful marker of psychological distress. As such, evidence of SCS’s association with SI can serve as a needed first step in validating the SCS among adolescents. Future research will need to assess the predictive validity of SCS in adolescents to suicidal behavior. Likewise, prior studies have shown SCS to be associated with both recent and lifetime suicidal thoughts and behavior [ 27 , 30 , 61 ]. One way to understand this is that some individuals may have a propensity towards SCS, such that it recurs under stress. To the extent this is the case, education about SCS might prove a potent preventative tool. Conclusions In conclusion, in the context of its limitations, the present study provides important preliminary evidence of the construct validity of Suicidal Crisis Syndrome in a community-based adolescent population. Future research can replicate and expand upon these findings, supporting the development of a potentially valuable new tool for prevention of adolescent suicide and suicide-related behavior. Abbreviations SI, suicidal ideation; SCS, Suicide Crisis Syndrome; DSM-5-TR, Diagnostic and Statistical Manual for Psychiatric Disorders, 5 th Edition, Text Revision; NTNU, Norwegian University of Science and Technology; HUNT, The Trøndelag Health Study ( Helseundersokelsen i Trøndelag ); SCS-YHP, proxy Young-HUNT3 SCS; HSCL-5, the 5-item Hopkins Symptoms Checklist; SCI-2 Suicide Crisis Inventory, 2 nd edition; SCS-C, the Suicide Crisis Syndrome Checklist; SCI-SF, the Suicide Crisis Inventory short form; A-SCS-C, Abbreviated Suicide Crisis Syndrome Checklist; Y-SCI, Youth Suicide Crisis Inventory. Declarations Ethics approval and consent to participate The project was approved by the Regional Committee for Medical and Health Research Ethics – Southeast Norway (ref. 2018/1037) in accordance with the Declaration of Helsinki. Consent for publication Written informed consent was obtained from all participants and parents of those under age 16. Availability for data and materials The HUNT data can be accessed from the HUNT Research Centre but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. To access HUNT data, researchers must gain project approval from the Regional Committee for Medical and Health Research Ethics and submit an application to the HUNT Research Centre. Applications must be made via a collaboration with a Norwegian principal investigator. More information is available at www.ntnu.edu/hunt/data Competing interests The authors declare that they have no competing interests. Funding This work was supported by the American Foundation for Suicide Prevention under grant #TBT-1-136-22 (PI: Igor Galynker, MD, PhD). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors contributions IG, AEV, and ZY initiated the project, designed the study aims, selected the items for the SCS-YHP, and edited the manuscript. LJC designed and performed the data analysis, performed the literature review and wrote up the results. TF helped prepare the data set, ran the data analysis in conjunction with LJC, and reviewed the manuscript. SBE reviewed and edited the manuscript and consulted on data analysis. SK and OKD organized and extracted the relevant data from the HUNT study, reviewed the manuscript, and provided expertise on HUNT processes. BY contributed to the literature review and edited the manuscript. Acknowledgements Not applicable References World Health Organization. Suicide [Internet]. 2025. Available from: https://www.who.int/news-room/fact-sheets/detail/suicide Hua LL, Lee J, Rahmandar MH, Sigel EJ. Suicide and suicide risk in adolescents. Pediatrics. 2024;153(1):1. 10.1542/peds.2023-064800 . Bertuccio P, Amerio A, Grande E, La Vecchia C, Costanza A, Aguglia A et al. Global trends in youth suicide from 1990 to 2020: an analysis of data from the WHO mortality database. EClinicalMedicine. 10.1016/j.eclinm.2024.102506 Our World in Data. Suicide rate, by age [Internet]. Available from: https://ourworldindata.org/grapher/suicide-rates-by-age-detailed-who Romer D. Adolescent risk taking, impulsivity, and brain development: Implications for prevention. Dev Psychobiol. 2010;52(3):263–76. 10.1002/dev.20442 . Sisk LM, Gee DG. Stress and adolescence: vulnerability and opportunity during a sensitive window of development. Curr Opin Psychol. 2022;44:286–92. 10.1016/j.copsyc.2021.10.005 . Spear LP. Heightened stress responsivity and emotional reactivity during pubertal maturation: Implications for psychopathology. Dev Psychopathol. 2009;21(1):87–97. 10.1017/S0954579409000066 . Brunstein Klomek A, Barzilay S, Apter A, Carli V, Hoven CW, Sarchiapone M, et al. Bi-directional longitudinal associations between bullying victimization, suicidal ideation/attempts, and depression. J Child Psychol Psychiatry. 2019;60(2):209–15. 10.1111/jcpp.12951 . Parellada M, Saiz P, Moreno D, Vidal J, Llorente C, Alvarez M, et al. Is attempted suicide different in adolescents and adults? Psychiatry Res. 2008;157(1–3):131–7. 10.1016/j.psychres.2007.02.012 . Steele IH, Thrower N, Noroian P, Saleh FM. Understanding suicide across the lifespan: A United States perspective of suicide risk factors, assessment & management. J Forensic Sci. 2018;63(1):162–71. 10.1111/1556-4029.13519 . Cabezas-Klinger H, Fernandez-Daza FF, Mina-Paz Y. Associations between social media use and mental disorders in adolescents and young adults: a systematic review and meta-analysis. Behav Sci. 2025;15(11):1450. 10.3390/bs15111450 . Marengo D, Settanni M, Mastrokoukou S, Fabris MA, Longobardi C. Social media linked to early adolescent suicidal thoughts via cyberbullying and internalizing symptoms. Int J Bullying Prev. 2024. 10.1007/s42380-024-00269-y . Silverman MM, Berman AL. Suicide risk assessment and risk formulation part I: A focus on suicide ideation in assessing suicide risk. Suicide Life Threat Behav. 2014;44(4):420–31. 10.1111/sltb.12065 . Cohen LJ, Imbastaro B, Peterkin D, Bloch-Elkouby S, Wolfe A, Galynker I. A suicide-specific diagnosis—the case for. Crisis. 2023;44(3):175–82. 10.1027/0227-5910/a000911 . Hallford DJ, Rusanov D, Winestone B, Kaplan R, Fuller-Tyszkiewicz M, Melvin G. Disclosure of suicidal ideation and behaviours: A systematic review and meta-analysis of prevalence. Clin Psychol Rev. 2023;101:102272. 10.1016/j.cpr.2023.102272 . Høyen KS, Solem S, Cohen LJ, Prestmo A, Hjemdal O, Vaaler AE, et al. Non-disclosure of suicidal ideation in psychiatric inpatients: Rates and correlates. Death Stud. 2022;46(8):1823–31. 10.1080/07481187.2021.1879317 . Bloch-Elkouby S, Zilcha-Mano S, Rogers ML, Park JY, Manlongat K, Krumerman M, et al. Who are the patients who deny suicidal intent? Acta psychiatrica Scandinavica. 2023;147(2):205–16. 10.1111/acps.13511 . Blanchard M, Farber BA. It is never okay to talk about suicide: patients’ reasons for concealing suicidal ideation in psychotherapy. Psychother Res. 2020;30(1):124–36. 10.1080/10503307.2018.1543977 . Kleiman EM, Turner BJ, Fedor S, Beale EE, Huffman JC, Nock MK. Examination of real-time fluctuations in suicidal ideation and its risk factors: Results from two ecological momentary assessment studies. J Abnorm Psychol. 2017;126(6):726–38. 10.1037/abn0000273 . Deisenhammer EA, Ing CM, Strauss R, Kemmler G, Hinterhuber H, Weiss EM. The duration of the suicidal process: how much time is left for intervention? J Clin Psychiatry. 2009;70(1):19–24. Paashaus L, Forkmann T, Glaesmer H, Juckel G, Rath D, Schönfelder A, et al. From decision to action: Suicidal history and time between decision to die and actual suicide attempt. Clin Psychol Psychother. 2021;28(6):1427–34. 10.1002/cpp.2580 . Bloch-Elkouby S, El-Hayek R, Cohen L, Chen JP, Gorman B, Apter Y, et al. The clinician rated suicide crisis syndrome checklist (SCS-C): structure, reliability, and concurrent validity among adult psychiatric inpatients. J Affect Disord. 2026;402:121341. 10.1016/j.jad.2026.121341 . Melzer L, Forkmann T, Teismann T. Suicide crisis syndrome: A systematic review. Suicide Life Threat Behav. 2024;54(3):556–74. 10.1111/sltb.13065 . American Psychiatric Association. Diagnostic and statistical manual of mental disorders . 5th ed. text rev. Washington (DC): American Psychiatric Association; 2022. Bloch-Elkouby S, Gorman B, Schuck A, Barzilay S, Calati R, Cohen LJ, et al. The suicide crisis syndrome: a network analysis. J Couns Psychol. 2020;67(5):595–607. 10.1037/cou0000423 . Bafna A, Rogers ML, Galynker II. Predictive validity and symptom configuration of proposed diagnostic criteria for the suicide crisis syndrome: a replication study. J Psychiatr Res. 2022;156:228–35. 10.1016/j.jpsychires.2022.10.027 . Bloch-Elkouby S, Barzilay S, Gorman BS, Lawrence OC, Rogers ML, Richards J, et al. The revised suicide crisis inventory (SCI-2): validation and assessment of prospective suicidal outcomes at one month follow-up. J Affect Disord. 2021;295:1280–91. 10.1016/j.jad.2021.08.048 . Park JY, Rogers ML, Bloch-Elkouby S, Richards JA, Lee S, Galynker I, et al. Factor structure and validation of the revised suicide crisis inventory in a Korean population. Psychiatry Investig. 2023;20(2):162–73. 10.30773/pi.2022.0208 . Wu CY, Lee JI, Lee MB, Rogers ML, Chan CT, Chen CY, et al. Identification of suicidality by five-item suicide crisis scale (SCS-5) in an online general population survey in Taiwan. J Suicidol. 2022;17(4):342–51. 10.30126/JoS.202212_17(4).0003 . Barzilay S, Assounga K, Veras J, Beaubian C, Bloch-Elkouby S, Galynker I. Assessment of near-term risk for suicide attempts using the suicide crisis inventory. J Affect Disord. 2020;276:183–90. 10.1016/j.jad.2020.06.053 . Yaseen ZS, Hawes M, Barzilay S, Galynker I. Predictive validity of proposed diagnostic criteria for the suicide crisis syndrome: An acute presuicidal state. Suicide Life Threat Behav. 2019;49(4):1124–35. 10.1111/sltb.12495 . Galynker I, Cohen L, Prekas AS, Bloch-Elkouby S, King M, Apter Levy Y. Suicide crisis syndrome: examining supporting evidence and barriers to diagnostic validity. Front Psychiatry. 2025;16:1627463. 10.3389/fpsyt.2025.1627463 . Karsen E, Cohen LJ, White B, De Luca GP, Goncearencoa I, Galynker II, et al. Impact of the abbreviated suicide crisis syndrome checklist on clinical decision making in the emergency department. J Clin Psychiatry. 2023;84(3):22m14655. 10.4088/JCP.22m14655 . Cohen LJ, White BJ, Miller FE, Karsen EF, Galynker II. Diagnosis of the suicide crisis syndrome in the emergency department associated with significant reduction in 3-month readmission rates. J Clin Psychiatry. 2024;85(4):24m15320. 10.4088/JCP.24m15320 . Osváth P, Molnár C, Lovig C, Major FN, Venczák S, Fekete S, et al. Assessment of acute suicide risk: Opportunities for comprehensive risk evaluation in clinical practice. Orv Hetil. 2025;166(4):146–53. 10.1556/650.2025.33211 . Leavey G, Rothi D, Paul R. Trust, autonomy and relationships: the help-seeking preferences of young people in secondary level schools in London (UK). J Adolesc. 2011;34(4):685–93. 10.1016/j.adolescence.2010.09.004 . Hubers AAM, Moaddine S, Peersmann SHM, Stijnen T, van Duijn E, van der Mast RC, et al. Suicidal ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: A meta-analysis. Epidemiol Psychiatr Sci. 2018;27(2):186–98. 10.1017/S2045796016001049 . Large M, Smith G, Sharma S, Nielssen O, Singh SP. Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatr Scand. 2011;124(1):18–29. 10.1111/j.1600-0447.2010.01672.x . McHugh CM, Corderoy A, Ryan CJ, Hickie IB, Large MM. Association between suicidal ideation and suicide: meta-analyses of odds ratios, sensitivity, specificity and positive predictive value. BJPsych Open. 2019;5(2):e18. 10.1192/bjo.2018.88 . Nock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA, Zaslavsky AM, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents. JAMA Psychiatry. 2013;70(3):1–11. 10.1001/2013.jamapsychiatry.55 . Bearman PS, Moody J. Suicide and friendships among American adolescents. Am J Public Health. 2004;94(1):89–95. 10.2105/AJPH.94.1.89 . López-Díaz Á, Palermo-Zeballos FJ, Gutierrez-Rojas L, Alameda L, Gotor-Sánchez-Luengo F, Garrido-Torres N, et al. Proxy measures for the assessment of psychotic and affective symptoms in studies using electronic health records. BJPsych Open. 2024;10:e22. 10.1192/bjo.2023.623 . Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr. 2008;8(1):24. 10.1186/1471-2318-8-24 . Holmen TL, Bratberg G, Krokstad S, Langhammer A, Hveem K, Midthjell K, et al. Cohort profile of the Young-HUNT study, Norway: a population-based study of adolescents. Int J Epidemiol. 2014;43(2):536–44. 10.1093/ije/dys232 . Kirkøen B, Ørstavik RE, Reneflot A, Skogen JC, Sivertsen B, Knudsen AKS. The ability of the Hopkins Symptom Checklist-5 to identify generalized anxiety disorder and major depressive disorder in the general population. Int J Environ Res Public Health. 2025;22(5):698. 10.3390/ijerph22050698 . Monaghan TF, Rahman SN, Agudelo CW, Wein AJ, Lazar JM, Everaert K, et al. Foundational statistical principles in medical research: Sensitivity, specificity, positive predictive value, and negative predictive value. Med (Kaunas). 2021;57(5):503. 10.3390/medicina57050503 . Bilén K, Ponzer S, Ottosson C, Castrén M, Pettersson H. Deliberate self-harm patients in the emergency department: who will repeat and who will not? Emerg Med J. 2013;30(8):650–6. 10.1136/emermed-2012-201235 . Steeg S, Kapur N, Webb R, Applegate E, Stewart SLK, Hawton K, et al. The development of a population-level clinical screening tool for self-harm repetition and suicide: The ReACT self-harm rule. Psychol Med. 2012;42(11):2383–94. 10.1017/S0033291712000347 . Rogers ML, McMullen L, Liang Y, Perez N, Richards JA, Akülker G, et al. Cross-national presence and sociodemographic correlates of the suicide crisis syndrome. J Affect Disord. 2023;329:1–8. 10.1016/j.jad.2023.02.076 . Anne E. Casey Foundation. Youth mental health statistics. 2025. https://www.aecf.org/blog/youth-mental-health-statistics . Accessed 24 Mar 2026. Centers for Disease Control and Prevention. Data and statistics on children’s mental health. 2025. https://www.cdc.gov/children-mental-health/data-research/index.html . Accessed 24 Mar 2026. Husky MM, Léon C, Vasiliadis HM. Increases in suicidal thoughts disclosure among adults in France from 2000 to 2021. J Affect Disord. 2025;371:54–60. 10.1016/j.jad.2024.11.042 . Farhane-Medina NZ, Luque B, Tabernero C, Castillo-Mayén R. Factors associated with gender and sex differences in anxiety prevalence and comorbidity: A systematic review. Sci Prog. 2022;105(4):368504221135469. 10.1177/00368504221135469 . Magovcevic M, Addis ME. The masculine depression scale: Development and psychometric evaluation. Psychol Men Masc. 2008;9(3):117–32. 10.1037/1524-9220.9.3.117 . De Luca GP, Parghi N, El Hayek R, Bloch-Elkouby S, Peterkin D, Wolfe A, et al. Machine learning approach for the development of a crucial tool in suicide prevention: The Suicide Crisis Inventory-2 (SCI-2) short form. PLoS ONE. 2024;19(5):e0299048. 10.1371/journal.pone.0299048 . Høyen KS, Cohen LJ, Solem S, Prestmo A, Sørensen K, Salvesen Ø, et al. Exploring associations between the MARIS questionnaire and recent suicidal ideation and behavior among patients admitted at an acute psychiatric inpatient department. Nord J Psychiatry. 2023;77(3):266–75. 10.1080/08039488.2022.2100929 . Chistopolskaya KA, Rogers ML, Enikolopov SN, Kravtsova NA, Sadovnichaya V, Drovosekov S. Adaptation of the suicide crisis inventory (SCI-2) in a Russian internet sample during the COVID-19 epidemic. Suicidology Russia. 2022;13:88–104. 10.32878/suiciderus.22-13-01(46)-88-104 . Peper-Nascimento J, Rogers ML, Richards JA, Diaz AP, Ceretta LB, Keller GS, et al. Suicide crisis inventory-2: factor structure, internal consistency, and validity in a Brazilian sample. Rev Bras Psiquiatr. 2024;46:e20233366. 10.47626/1516-4446-2023-3366 . Jaycox LH, Murphy ER, Zehr JL, Pearson JL, Avenevoli S. Social media and suicide risk in youth. JAMA Netw Open. 2024;7(10):e2441499. 10.1001/jamanetworkopen.2024.41499 . Xiao Y, Bi K, Yip PSF, Cerel J, Brown TT, Peng Y, et al. Decoding suicide decedent profiles and signs of suicidal intent using latent class analysis. JAMA Psychiatry. 2024;81(6):595. 10.1001/jamapsychiatry.2024.0171 . Cohen LJ, Ardalan F, Yaseen Z, Galynker I. Suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life-Threatening Behav. 2018;48(5):613–23. 10.1111/sltb.12387 . Footnotes Cohen LJ, Vaaler A, Yaseen Z, Høyen K, Galynker I. SCS proxy measure predicts future deliberate self-harm and death by suicide in a population-wide survey study. Unpublished manuscript; 2026. Barzilay S. Suicide Crisis Syndrome-based adaptive screening in adolescents. Presented at: International Summit on Suicide Research; 2025 Nov 8–11; Boston, MA, United States. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 04 May, 2026 Reviews received at journal 01 May, 2026 Reviewers agreed at journal 30 Apr, 2026 Reviewers agreed at journal 30 Apr, 2026 Reviewers invited by journal 30 Apr, 2026 Editor invited by journal 22 Apr, 2026 Editor assigned by journal 22 Apr, 2026 Submission checks completed at journal 22 Apr, 2026 First submitted to journal 20 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9473762","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634142686,"identity":"841d5cef-e5e4-4076-9547-17a81b134540","order_by":0,"name":"Lisa J. Cohen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIiWNgGAWjYBACPmYgIQHEBgwMjA8gYowNYC4uwIakhRmsjoegFhgDqIZNAqKFAGBjZ3/4wYLBTs6cvfdY1Y2Kw3n2/IfbHvwoYJAz71+Aw2E8xhISDMnGlj3n0m7nnDlczCOR2G7YY8BgLHPjAS4tDEAtBxI33Mgxu53bdjixR4KxTYLHgCFxhsQBHFrYH/8Aa7n/xqwYrIX/YJvkH7xaGMygtvCYMYO1MCS2SYNt4W/A5TAzCwmDZGODMznG0jln0hN7bgC1yBhIgLyIFfDzH398W6LCTs7g+BnDzzkV1ont/cefSb75YyMnwY/dYSDALIEl4oBWSCTg1ML4AYcLcNsyCkbBKBgFIwoAANuOUw5bFghNAAAAAElFTkSuQmCC","orcid":"","institution":"Icahn School of Medicine at Mount Sinai","correspondingAuthor":true,"prefix":"","firstName":"Lisa","middleName":"J.","lastName":"Cohen","suffix":""},{"id":634142688,"identity":"9cff2bbb-75a6-4774-a732-75817676797b","order_by":1,"name":"Tingting Feng","email":"","orcid":"","institution":"Norwegian University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Tingting","middleName":"","lastName":"Feng","suffix":""},{"id":634142689,"identity":"6204ac7e-e740-4953-86fa-ec26d1d7a83b","order_by":2,"name":"Arne E. Vaaler","email":"","orcid":"","institution":"Norwegian University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Arne","middleName":"E.","lastName":"Vaaler","suffix":""},{"id":634142699,"identity":"13a6287b-ae0f-4580-b19b-adb56340d130","order_by":3,"name":"Zimri Yaseen","email":"","orcid":"","institution":"Icahn School of Medicine at Mount Sinai","correspondingAuthor":false,"prefix":"","firstName":"Zimri","middleName":"","lastName":"Yaseen","suffix":""},{"id":634142706,"identity":"205aede0-97b9-4542-bf99-2a184858198a","order_by":4,"name":"Sarah Bloch ElKouby","email":"","orcid":"","institution":"Ferkauf Graduate School of Psychology, Yeshiva University","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"Bloch","lastName":"ElKouby","suffix":""},{"id":634142709,"identity":"966a0822-b49c-4d2e-90c7-f5c253f01055","order_by":5,"name":"Betty Yuabov","email":"","orcid":"","institution":"Icahn School of Medicine at Mount Sinai","correspondingAuthor":false,"prefix":"","firstName":"Betty","middleName":"","lastName":"Yuabov","suffix":""},{"id":634142715,"identity":"d5d8309a-d0d0-4b79-a588-d987b61c09f2","order_by":6,"name":"Ole K. Drange","email":"","orcid":"","institution":"Norwegian University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Ole","middleName":"K.","lastName":"Drange","suffix":""},{"id":634142721,"identity":"60b56af6-2004-470a-92fb-0b9a381b3187","order_by":7,"name":"Igor Galynker","email":"","orcid":"","institution":"Icahn School of Medicine at Mount Sinai","correspondingAuthor":false,"prefix":"","firstName":"Igor","middleName":"","lastName":"Galynker","suffix":""},{"id":634142725,"identity":"18f6cf75-cfed-403f-b5e7-d5c5003ba3f3","order_by":8,"name":"Steiner Krokstad","email":"","orcid":"","institution":"Norwegian University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Steiner","middleName":"","lastName":"Krokstad","suffix":""}],"badges":[],"createdAt":"2026-04-20 14:40:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9473762/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9473762/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109067825,"identity":"7e2bb22e-776c-4326-afde-3eb4d3727be4","added_by":"auto","created_at":"2026-05-12 10:01:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":643791,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9473762/v1/16558655-f3b4-46ea-9566-a1e4ce0cf8c7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Relationship Between the Suicide Crisis Syndrome and Suicidal Ideation in Adolescents: A Preliminary Validation Study Using Data from the Young-HUNT3 epidemiological study","fulltext":[{"header":"Background","content":"\u003cp\u003eSuicide is one of the main causes of death globally. In 2021, an estimated 727,000 people died by suicide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], more than died by breast cancer, war, homicide, HIV/AIDS or malaria. Suicide is a particularly serious problem among youth and was the 4th most common cause of death among people aged 15\u0026ndash;19 worldwide in 2021. Although the rate of youth suicide is higher among males than females [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], at a ratio of about 5 to 2 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], suicide is the 2nd most common cause of death for females in this age group [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In recent decades, the rate of youth suicide has increased in several countries, including the United States, United Kingdom, Australia, and Canada [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Likewise, suicide rates among youth aged 10\u0026ndash;24 rose from 1980 to 2020 in North America, Central-South America, and Asia-Oceania [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Clearly, youth suicide is a pressing public health problem requiring effective preventative strategies.\u003c/p\u003e \u003cp\u003eSuicidal behavior in adolescents may differ from that in adults in a number of dimensions. Adolescents tend to be more impulsive and affectively reactive than adults [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Likewise, they are more sensitive to interpersonal difficulties, which serve as a major trigger for suicidal behavior [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In a comparison of adult and adolescent psychiatric admissions following suicidal ideation or behavior, Parellada and colleagues [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] found that adolescents tended to use less lethal methods, were more uncertain in their intent and engaged in more impulsive behavior [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In a 2018 review by Steele and colleagues, adolescent risk factors for suicides and suicidal behaviors included insomnia, perceived burdensomeness, bullying, school problems, and recent conflict with a family or a romantic partner. In contrast, risk factors for adults included being male, substance abuse, low education, occupational, financial or legal distress and being single, divorced or widowed. Psychiatric illness, particularly depression, and prior suicide attempts crossed generational boundaries [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCyber bullying, in particular, has received more attention of late, and may be particularly damaging to adolescent girls [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Likewise, social media has come to play an increasingly dominant role in adolescents\u0026rsquo; lives and more frequent use has been linked to poorer mental health and suicidal ideation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Possible mechanisms include sleep interference, distraction from other activities, negative social comparisons, perceived peer exclusion and cyber bullying.\u003c/p\u003e \u003cp\u003eTraditionally, suicide risk assessment has relied almost exclusively on self-reported suicidal ideation (SI) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], which poses numerous challenges [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Suicidal individuals may choose not to disclose SI [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], often to avoid hospitalization, embarrassment, or feared judgment [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Likewise, SI is highly variable and can fluctuate dramatically throughout the day [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In studies by Deisenhammer and colleagues [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and Paashaus and colleagues [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], more than 40% of study participants reported less than 10 minutes between the onset of SI and suicidal action. This time frame might be even shorter among adolescents given their elevated impulsivity.\u003c/p\u003e \u003cp\u003eIn response to these limitations, increasing attention in recent years has been directed to the concept of a suicidal mental state. The Suicide Crisis Syndrome (SCS), in particular, has been extensively researched. The SCS has shown robust associations with near-term suicidal behavior (See [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] for reviews) and is currently under consideration for inclusion in the Diagnostic and Statistical Manual for Psychiatric Disorders (DSM-5-TR) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The SCS describes a hyperaroused, negative affective-cognitive state characterized by a profound sense of entrapment. Fifteen symptoms are categorized into 5 criteria that together comprise a unified construct [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Criterion A is Entrapment, defined as an overpowering sense of being trapped in an intolerable and inescapable situation. Criterion B, Associated Features, has four subcriteria. Criterion B1, Affective Distress, refers to acute and severe emotional distress, psychological pain or mood lability. Criterion B2, Disturbances in Arousal, refers to a hyperaroused and agitated state characterized by hypervigilance, extreme tension or insomnia. Criterion B3, Loss of Cognitive Control, refers to a profusion of negative thoughts, overwhelming rumination and the inability to shift attention or think flexibly. Criterion B4, Acute Social Withdrawal, refers to a recent and abrupt withdrawal from social connections and/or evasive communication. Individuals meet criteria for SCS if they score positively on at least one symptom from all 5 domains [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo date, all studies published on the SCS have been conducted with adult populations. Across multiple independent samples, confirmatory factor analyses have shown SCS to be a coherent, unitary construct with five separate subdomains [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Within both clinical and community adult samples, the SCS was found to predict near-term suicidal ideation and behavior [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and did so over and above traditional risk factors such as depressive symptoms and suicidal ideation [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. A measure of the SCS was also shown to predict long term risk of suicide death\u003csup\u003e1\u003c/sup\u003e. Further, discriminant validity over depression, obsessive compulsive disorder, personality and posttraumatic stress disorders have also been demonstrated [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Moreover, measures of the SCS have been adapted and implemented into standard clinical procedures in psychiatric settings in the United States [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] and Hungary [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], where they have demonstrated high clinical utility with regard to clinical decision making [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause of adolescents\u0026rsquo; unique developmental challenges, exclusive reliance on suicidal ideation for risk assessment might be even more problematic than with adults. Adolescents are known to be more impulsive and emotionally reactive even than younger children and are often reluctant to confide in adults [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. As such, assessment of an acute negative affect state may be of heightened clinical utility in suicide prevention. Moreover, such a state may be more easily detected by parents, teachers, friends and other family members, allowing for more timely interventions, even when adolescents are reluctant to self-disclose SI. Likewise, adolescents themselves can be educated to recognize these symptoms and to seek out support before they escalate to a dangerous level. Currently, there are no published studies of SCS in adolescents although an Israeli study of 335 adolescents presenting to the emergency room has been completed and publicly presented\u003csup\u003e2\u003c/sup\u003e. Of note, the Barzilay study assesses a clinical population, such that SCS remains untested in the general adolescent population.\u003c/p\u003e \u003cp\u003eThe present study assesses the relationship between SCS symptoms and history of suicidal ideation in a sample of 3,195 adolescents surveyed in the Young-HUNT3 epidemiological study from the Tr\u0026oslash;ndelag district of Norway. Although, as noted above, SI is a problematic marker of imminent risk of suicide, it is still a worthwhile target of study. It is indicative in and of itself of a high level of distress and the risk of either suicidal attempt or death by suicide is meaningfully higher in people with suicidal ideation than without [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Specifically, in an epidemiological study of 6,483 adolescents in the United States, one third of the participants with SI later attempted suicide [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Moreover, as a preliminary step, it is critical to link SCS among adolescents with an established marker of suicidal risk.\u003c/p\u003e \u003cp\u003eThe HUNT studies are designed to provide a comprehensive picture of public health in the Norwegian district of Tr\u0026oslash;ndelag and include a section on mental health. Young-HUNT3 was aimed at adolescents aged 13 to 20 and conducted between 2006 and 2008. Although Young-HUNT3 did not include a validated measure of SCS, items from the mental health section of the survey were extracted to create a proxy measure of SCS, a research design which has been utilized previously [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Likewise, across many fields of study, proxy or derived measures are frequently used with epidemiological data when the phenomenon of interest was not addressed in the original research design [\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Of note, this study serves as a companion study to an initial SCS-HUNT study, testing the predictive validity of a proxy measure of SCS in adults to deliberate self-harm and death by suicide\u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe hypotheses tested in this study are:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAdolescents who meet criteria for SCS will have reported an increased rate of lifetime suicidal ideation, with high levels of sensitivity and specificity.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSCS will show incremental concurrent validity for suicidal ideation, after controlling for age and sex, two characteristics previously associated with suicidal risk [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSuicidal ideation will be independently associated with each of the 5 SCS criteria after controlling for intercorrelations.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eTo the extent these hypotheses are supported, this will provide an important first step in demonstrating construct validity for the SCS in adolescents.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCollaboration\u003c/h2\u003e \u003cp\u003eThis study was conducted as part of a collaboration between a research team at the Icahn School of Medicine at Mount Sinai in New York City and researchers at the Norwegian University of Science and Technology (NTNU) in Trondheim, Norway. A collaboration agreement between the two institutions specified the scope of work and the procedures for data sharing. The project was approved by the Regional Committee for Medical and Health Research Ethics \u0026ndash; Southeast Norway (ref. 2018/1037).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSource of Data\u003c/h3\u003e\n\u003cp\u003eThe Tr\u0026oslash;ndelag Health Study (Helseundersokelsen i Tr\u0026oslash;ndelag: HUNT) is a population-wide survey on health and health behaviors sent to all residents of Tr\u0026oslash;ndelag County in Norway. HUNT is a collaboration between HUNT Research Centre (Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU), Tr\u0026oslash;ndelag County Council, Central Norway Regional Health Authority, and the Norwegian Institute of Public Health. HUNT3 was the third of a series starting in 1984 and took place between October, 2006 and June, 2008.\u003c/p\u003e \u003cp\u003eYoung-HUNT3 was the adolescent component of HUNT3. Recruitment took place largely through junior high and high schools. After the principal of each of the 66 schools in the district gave written consent for the school\u0026rsquo;s participation, invitation letters were sent to all students and their parents or guardians describing the study and use of data. All participants and parents of those under age 16 provided written informed consent. For all participating students, an anonymized questionnaire was administered in a school classroom in an \u0026ldquo;exam-like setting.\u0026rdquo; Approximately one month later, a nurse visited the school for follow-up interviews and physical measurements. Data for this study was drawn solely from the questionnaire.\u003c/p\u003e \u003cp\u003eAdolescents not in school were contacted by mail and invited to complete the questionnaire and to attend an adult screening site. Young-HUNT was approved by the Norwegian Data Inspectorate, the Regional and National Committees for Medical and Health Research Ethics and the Norwegian Directorate of Health. See [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] for a detailed description of the Young-HUNT studies.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eOf the 10,464 adolescents invited to participate in the Young-HUNT3 study, 5,614 (53.7%) were in junior high school, 4,357 (41,6%) were in high school, and 493 (4.7%) were not in school. Of those invited, 8,200 (78.4%) completed the questionnaire. The response rate was 84.6% for junior high students, 76.6% for high school students, and 23.3% for adolescents not in school [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eProxy SCS measure (SCS-YHP)\u003c/h2\u003e \u003cp\u003eItems for the proxy Young-HUNT3 SCS (SCS-YHP) were extracted from the baseline questionnaire, which incorporated items from multiple sources. Items for Criteria A, B1, B2 and B3a were drawn from the 5-item Hopkins Symptoms Checklist (HSCL-5), a widely used, 5-item questionnaire measuring emotional distress [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Additional items assessing social isolation and insomnia (Criteria B3b and B4) were extracted from questionnaires designed by the Norwegian Institute of Public Health. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for description of the items and scoring criteria.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eScoring Criteria for the SCS Proxy Measures \u003cem\u003eNote\u003c/em\u003e. SCS YHP\u0026thinsp;=\u0026thinsp;Suicide crisis Syndrome Young-HUNT Proxy. Variables in the HUNT study can be reviewed at the following link: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hunt-db.medisin.ntnu.no/hunt-db/variablelist\u003c/span\u003e\u003cspan address=\"https://hunt-db.medisin.ntnu.no/hunt-db/variablelist\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS Criteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eData Source\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHUNT Variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCoding Scheme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion A: Entrapment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHopkins Symptom Checklist (SCL-5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast 14 days felt hopelessness when you think of the future?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Very bothered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B1: Affective Disturbance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHopkins Symptom Checklist (SCL-5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB1b or B1c\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B1b: Depressive Turmoil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHopkins Symptom Checklist (SCL-5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast 14 days felt dejected or sad?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Very bothered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B1c: Extreme Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHopkins Symptom Checklist (SCL-5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast 14 days been constantly afraid and anxious?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Very bothered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B2: Loss of Cognitive Control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHopkins Symptom Checklist (SCL-5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast 14 days worried too much about various things?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Very bothered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B3: Hyperarousal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB3a or B3b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B3a: Agitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHopkins Symptom Checklist (SCL-5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast 14 days felt tense or uneasy?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Very bothered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B3b: Global Insomnia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorwegian Institute of Public Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast month had difficulty falling asleep in the evening?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;Almost every night\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B3b: Global Insomnia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorwegian Institute of Public Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast month woke too early and couldn\u0026rsquo;t fall asleep again?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;Almost every night\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B4: Acute Social Withdrawal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorwegian Institute of Public Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAny of the items below are positive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorwegian Institute of Public Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHow many close friends? Those you can confide in and who help you when you need help.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;None or one\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorwegian Institute of Public Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHow often have you visited someone you know?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;None\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorwegian Institute of Public Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHow often have you gone out with friends more than two hours in a row?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;None\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion A3: Entrapment modified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast 14 days felt hopelessness when you think of the future?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;quite bothered or\u003c/p\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;very bothered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion B1.3: Affective Disturbance modified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLast 14 days been constantly afraid and anxious?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;quite bothered or 4\u0026thinsp;=\u0026thinsp;very bothered or B1b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCalculated Scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSee above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSCS A, B1, B2, B3 and B4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCalculated Scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSee above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSCS A and B1, B2, B3 or B4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCalculated Scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSee above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSCS A3, B1.3, B2, B3, and B4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e. SCS YHP = Suicide crisis Syndrome Young-HUNT Proxy. Variables in the HUNT study can be reviewed at the following link: https://hunt-db.medisin.ntnu.no/hunt-db/variablelist\u0026nbsp;\u003c/p\u003e \u003cp\u003eSCS-YHP is a binary variable marking the presence or absence of SCS. In keeping with previously established criteria for the proposed DSM diagnosis [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], participants with at least one symptom in each domain were rated to meet criteria for that domain. The number of domains required for the final binary rating of SCS varied, however, as is detailed below.\u003c/p\u003e \u003cp\u003eInitially, the SCS-YHP was designed theoretically, based on face validity. As there were no means of measuring criterion validity within the Young-HUNT3 dataset, we developed two alternative versions to provide sensitivity analyses of the relationship between SCS and suicidal ideation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSCS-YHP 1.\u003c/span\u003e This first measure was the most stringent. In accord with the proposed DSM SCS criteria, a positive rating on all 5 criteria was required for a positive SCS diagnosis.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSCS-YHP 2.\u003c/span\u003e Because of the small percent of study participants scoring positively using SCS-YHP 1 (N\u0026thinsp;=\u0026thinsp;19, 0.24%), a less stringent measure was designed, requiring only Criterion A plus any of Criteria B1-B4 to be positive. Although these criteria differ from the proposed DSM SCS diagnostic criteria, a similar metric has been successfully used clinically in hospital systems in Chicago, Illinois [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] and Pecs, Hungary [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Further, prior studies have demonstrated predictive validity with different combinations of the 5 SCS criteria [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In all such cases, however, Entrapment/Frantic Hopelessness (Criterion A) is required.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSCS-YHP 3.\u003c/span\u003e To maintain consistency with the proposed DSM SCS diagnosis but still relax inclusion criteria, a second alternative scoring system was designed. SCS-YHP 3 maintained the requirement of all 5 SCS criteria but loosened the criteria for Criterion A and Criterion B1 (See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e[INSERT\u003c/b\u003e Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003eHERE]\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSuicidal Ideation\u003c/h2\u003e \u003cp\u003eSuicidal ideation was assessed with the question: Have you ever had thoughts of taking your own life? History of suicidal behavior (e.g., attempts, gestures) was not assessed in Young-HUNT3 so could not be assessed in this study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDemographic and clinical characteristics\u003c/h3\u003e\n\u003cp\u003eInformation on age, sex, and impairment due to mental health problems (coded no, a little, somewhat or severely) was also extracted from the baseline questionnaire. In Young-HUNT3, sex was coded only as male vs. female.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eInitial analyses provided descriptive data to characterize the SCS results in this sample. To test concurrent validity in Hypothesis 1, logistic regression regressed suicidal ideation on SCS-YHP. Sensitivity and specificity were also assessed. To test incremental validity in Hypotheses 2, age and sex were added to the models. Due to the low case rate for all three models, positive and negative predictive values were not calculated as they are dependent on prevalence within the population [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. To test the independent validity of each domain in Hypothesis 3, SI was regressed against all five domain scores. Given the potential for heteroscedasticity in the data, we utilized robust standard errors to enhance the reliability of our estimates. For sensitivity analyses, all hypotheses were tested using all three SCS-HP formats. Missing data was handled listwise; only records with complete data were included in each analysis. To preserve power given the low case rate, we elected to include all available data in each analysis even though sample size varied depending on the variables included. All data was analyzed with STATA v. 180/MP. The AI platform POE was used solely to help format commands for data analysis in STATA.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe entire sample used for analysis included 8,199 participants. Of these, 8,041 had sufficient data for SCS-HYP 1; 19 participants (0.23%) rated SCS positive and 8,022 (97.8%) rated negative. With the more inclusive SCS-YHP 2, there was, as expected, a larger case rate (N\u0026thinsp;=\u0026thinsp;176, 2.21% of 7,979). The final model, SCS-YHP 3, yielded 25 cases (0.31% of 8,039). Although not consistent across SCS-YHP formats, participants meeting criteria for SCS were younger than their non-SCS counterparts and more likely to be females than males. Across all 3 formats, participants meeting criteria for SCS reported dramatically higher rates of impairment due to a mental health condition, at least 20 times more likely to rate high/severe impairment vs. no/a little. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Clinical Features in Relation to SCS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS Format\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSCS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo SCS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEffect Size\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 1 (N\u0026thinsp;=\u0026thinsp;8,041)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (0.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8,022 (99.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e(1)\u0026thinsp;=\u0026thinsp;4.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;2.74, 95% CI: 0.99, 7.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,056 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e*Fisher\u0026rsquo;s exact\u0026thinsp;=\u0026thinsp;0.06, p \u0026gt; .05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,966 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge: mean (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.71\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.88\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et(8,039)= -2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e(1)\u0026thinsp;=\u0026thinsp;131.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.00001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;31.82, 95% CI: 12.6, 80.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, a little\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162 (2.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7,089 (88.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat/ severely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (42.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (57.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 2 (N\u0026thinsp;=\u0026thinsp;7,977)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e176 (2.21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7801 (97.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e(1)\u0026thinsp;=\u0026thinsp;23.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;2.17, 95% CI: 1.60, 3.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121 (2.99%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3922 (97.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (1.40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3881 (98.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge: mean (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.47\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.87\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et [7,977] = -4.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e(1)\u0026thinsp;=\u0026thinsp;456.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.00001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;20.8, 95% CI: 14.2, 30.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, a little\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125 (1.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,939 (98.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat/severely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 3 (N\u0026thinsp;=\u0026thinsp;8039)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (0.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8,014 (99.69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e(1)\u0026thinsp;=\u0026thinsp;6.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;3.11, 95% CI: 1.24, 7.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (0.47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,051 (99.53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFisher\u0026rsquo;s exact\u0026thinsp;=\u0026thinsp;0.147, p\u0026lt;.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (0.15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,963 (99.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge: mean (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.38\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.88\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et (8037) = -1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e(1)\u0026thinsp;=\u0026thinsp;130.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.00001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u0026thinsp;=\u0026thinsp;26.4, 95% CI: 11.4, 61.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, a little\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (0.02%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7,083 (99.79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat/ severely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (5.29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e161 (94.70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote\u003c/em\u003e. SCS YHP\u0026thinsp;=\u0026thinsp;Suicide crisis Syndrome Young-HUNT Proxy. OR= Odds Ratio. *Fisher\u0026rsquo;s exact test provided [by socsci] when cell size is 6 or under. (Cohen\u0026rsquo;s d first checked on POE and then validated on socscIstatistics.com/effectsize/default3.aspx OR\u0026rsquo;s provided by POE\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e[INSERT\u003c/b\u003e Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003eHERE]\u003c/b\u003e\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eConcurrent Validity (Hypothesis 1)\u003c/h2\u003e \u003cp\u003eReported history of suicidal ideation was remarkably common in this sample. Almost a quarter (N\u0026thinsp;=\u0026thinsp;743, 23%) of the participants who answered the question (N\u0026thinsp;=\u0026thinsp;3,212) reported a history of suicidal ideation.\u003c/p\u003e \u003cp\u003eConcurrent validity was strong for all three formats, as presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Odds ratios ranged from 6.72 to 11.75 and were significant, at minimum, at the .002 level. This suggests that adolescents who were rated as SCS positive, by any of 3 different formats, were approximately 7\u0026ndash;12 times more likely to report a history of suicidal ideation. Of note the highest odds ratio was achieved for the most stringent model (SCS-YHP 1) although this difference between models was not significant, as indicated by the overlapping 95% confidence intervals.\u003c/p\u003e \u003cp\u003eSensitivity and specificity for each format were as follows: 77.8% and 77.0% for SCS-YHP 1; 67.0% and 78.3% for SCS-YHP 2; and 66.7% and 77.1% for SCS-YHP 3.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrediction to Suicidal Thoughts of the Three SCS formats: Logistic Regression Analyses\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS Format\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo SI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%LLCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%ULCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e56.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS-YHP 1 (ref.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e731 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,455 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS-YHP 2 (ref.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e666 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,408 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS-YHP 3 (ref.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e730 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,453 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote\u003c/em\u003e. SCS\u0026thinsp;=\u0026thinsp;Suicide Crisis Syndrome. SCS 1 requires all 5 criteria to be present, which parallels the proposed DSM diagnosis but generated a minimal cell size. SCS 2 requires Criterion A to be present plus one of Criteria B1-B4. This is less stringent but generates a larger cell size (N\u0026thinsp;=\u0026thinsp;91 in this analysis). SCS3 requires all 5 SCS criteria be met as with SCS 1 but relaxes the requirements for Criteria A and B1.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eIncremental Validity (Hypothesis 2)\u003c/h2\u003e \u003cp\u003eFor each format, concurrent validity held strong when age and sex were entered into the models. Adjusted odds ratios for the SCS ranged from 6.13 to 10.59. Although female sex was a significant risk factor in the three models, age was not. In this case too, the SCS-YHP1 achieved the highest odds ratio but the difference was not significant. (See Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIncremental Validity to Suicidal Ideation of Each SCS Format Controlled for Age and Sex\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS Format\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo SI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%LLCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%ULCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 1 (N\u0026thinsp;=\u0026thinsp;3,195)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e52.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS 1 (ref.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e731 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,455 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e311 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,228 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (ref.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e432 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,241 (74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge: mean (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.61 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.63 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.472\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 2 (N\u0026thinsp;=\u0026thinsp;3,165)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS 2 (ref.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e666 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,408 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e311 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,228 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (ref.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e432 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,241 (74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge: mean (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.61 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.63 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.385\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS-YHP 3\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;3,195)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS 3 (ref.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e730 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,453 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e311 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,228 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (ref.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e432 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,241 (74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge: mean (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.61 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.63 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.492\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote\u003c/em\u003e. SCS\u0026thinsp;=\u0026thinsp;Suicide Crisis Syndrome. SI= Suicidal Ideation. OR= Odds Ratio. SCS 1 requires all 5 criteria to be present, which parallels the proposed DSM diagnosis but generated a minimal cell size. SCS 2 requires Criterion A to be present plus one of Criteria B1-B4. This is less stringent but generates a larger cell size (N\u0026thinsp;=\u0026thinsp;91 in this analysis). SCS3 requires all 5 SCS criteria be met as with SCS 1 but relaxes the requirements for Criteria A and B1.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eIndependent validity of Each SCS Criterion (Hypothesis 3)\u003c/h2\u003e \u003cp\u003eTo test the independent relationships between the 5 SCS criteria and history of suicidal thoughts, two analyses were run, the first with the original 5 criteria and the second replacing Criteria A and B1 with the less stringent versions of these criteria used in SCS-YHP 3. In the first more stringent model, each SCS criterion was independently associated with suicidal thoughts. In the second model, all but B4, acute social withdrawal, were independently associated with suicidal thoughts. (See Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndependent Contributions of Each SCS criterion to Prediction of Concurrent Suicidal Thoughts\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS Criterion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSI\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo SI\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%ULCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%LLCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel 1 (N\u0026thinsp;=\u0026thinsp;3070)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (62.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS A (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e654 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,395 (78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS B1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (72.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (27.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS B1 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e629 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,397 (79.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS B2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 (59.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS B2 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e588 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2349 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS B3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111 (48.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117 (51.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS B3 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e605 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2287 (79.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS B4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e352 (70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS B4 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e578 (21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2063 (78.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel 2 (N\u0026thinsp;=\u0026thinsp;3071)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSI\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo SI\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%ULCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%LLCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*SCS3 A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e209 (51.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e201 (49.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS3 A (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e519 (18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2239 (81.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*SCS3 B1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137 (64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (35.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS3 B1 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e587 (19.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2358 (80.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS B2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 (59.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS B2 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e588 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2349 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS B3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111 (48.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117 (51.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS B3 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e605 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2287 (79.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCS B4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e352 (70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo SCS B4 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e578 (21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2063 (78.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote\u003c/em\u003e. SCS\u0026thinsp;=\u0026thinsp;Suicide Crisis Syndrome, AOR\u0026thinsp;=\u0026thinsp;adjusted odds ratio, LLCI\u0026thinsp;=\u0026thinsp;lower limit confidence interval, ULCI\u0026thinsp;=\u0026thinsp;upper limit confidence interval, *alternative, less stringent formats for Criteria SCS A and SCS B1 entered into Model 2 with the other SCS criteria.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary aim of this paper was to provide initial validation of the Suicide Crisis Syndrome in adolescents, specifically in a community population. We hypothesized that a proxy measure of the SCS extracted from the epidemiological Young-HUNT3 study would be associated with a history of suicidal ideation in youth aged 13\u0026ndash;20, that this relationship would have high sensitivity and specificity, and that it would be sustained after controlling for age and sex. Additionally, we hypothesized that each SCS domain would be independently associated with suicidal ideation. Indeed, in all three SCS formats, our hypotheses were supported, with the exception of SCS Criterion B4 in the analysis of SCS-YHP 3.\u003c/p\u003e \u003cp\u003eThis is, to our knowledge, one of the first studies showing construct validity for SCS in adolescents and the first within the general population. We believe that SCS can provide a valuable addition to suicide prevention in adolescents, who are often reluctant to disclose suicidal ideation to adults. Moreover, adolescents exhibit greater emotional reactivity and impulsivity than adults [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], which serve as strong drivers of suicidal behavior in this age group [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. SCS, a hyper-aroused, negative affect state, characterized by loss of cognitive control, precisely focuses on an emotionally dysregulated mental state strongly associated with suicidal thoughts and behavior [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. To the extent that family, friends, clinicians, teachers and adolescents themselves are educated about SCS, this can potentially provide a valuable early warning system for suicidal risk, flagging the possible need for intervention and support. Future research can demonstrate whether the clinical utility of SCS already documented in adults [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] can generalize to adolescents. Future research can also investigate treatment options for SCS as a stand-alone syndrome.\u003c/p\u003e \u003cp\u003eIn all three formats, the SCS-YHP showed relatively strong sensitivity and specificity. Sensitivity is arguably most important in risk assessment, such that people at risk are flagged and not overlooked. Lower specificity can be mitigated by treating the measure as an initial screen, identifying the need for further evaluation. Nonetheless, our specificity was also high, which is not always the case with suicide risk protocols [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt this stage, the incidence of SCS in adolescence is not known. Incidence in community populations of adults has ranged from 3.6% to 16.2% across countries [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. However, the reliance on self-selected samples in the online surveys used to collect these data may overestimate the incidence in the population while the use of proxy measures, such as the one in the current study and in the adult HUNT3 study\u003csup\u003e1\u003c/sup\u003e, likely underestimates the incidence. Importantly, in this epidemiological study, 23% of survey respondents who answered the question reported a history of suicidal ideation. Even if the 60% of survey participants with missing data denied history of SI, that would still indicate prior or current SI in at least 9.2% of this community population of adolescents. According to the Anne E. Casey Foundation [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], in 2022\u0026ndash;2023 in the United States, an estimated 18% of adolescents had at least one major depressive episode in the past year, while 20% reported symptoms of anxiety and 31% had a mental, emotional, developmental or behavioral problem. Given these statistics, it is highly likely that the actual incidence of SCS is higher than found in this study.\u003c/p\u003e \u003cp\u003eSCS was strongly associated with self-reported severe mental health impairment, with odds ratios consistently above 20. This supports the notion of SCS as a stand-alone psychiatric disorder, associated with distress and dysfunction even outside of its relation to suicide risk. We also found that older adolescents and females vs. males were more likely to meet criteria for SCS on the SCS-YHP, although this was not consistent across SCS-YHP formats. That females report a higher incidence of SCS than males is consistent with robust findings in the literature of greater incidence of depression, suicidal ideation and other internalizing disorders in girls and women [3. 51] The extent to which this reflects a true difference in prevalence rather than self-disclosure remains unclear [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] but it has also been shown that males are more likely to manifest emotional distress in externalizing disorders, that is in action rather than in subjective experience [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. In this regard, clinician ratings might offer advantages over self-report questionnaires. In adult samples, SCS has been more common in younger people [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], which is not consistent with the present findings. The younger age of participants without SCS may reflect the presence of pubertal or pre-pubertal adolescents who may not have fully encountered the challenges of adolescence, a consistent finding among youth studies [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. That the participation rate was highest (86%) among junior high students, who required parental consent, also suggests a possible self-selection bias towards greater health concerns in older students who elected to participate in the HUNT survey.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe findings of this study should be considered in the context of its limitations. For one, SCS was measured with a proxy measure extracted from the Young-HUNT3 study, which has not been validated against other validated SCS measures. While this proxy measure lacked evidence of criterion validity, that is convergent validity with published and validated measures of the SCS, its association with SI, as demonstrated across multiple formats, provides preliminary indication of construct validity. Likewise, proxy measures have frequently been derived from epidemiological data that did not include the measures of interest in its original design. This has been done across multiple fields, including suicide research and mental health [\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Future research should replicate the current findings with validated SCS measures, such as the Suicide Crisis Inventory, 2nd edition (SCI-2) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], the SCS-Checklist (SCS-C) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], the SCI-short form (SCI-SF) [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], or the Abbreviated SCS-C (A-SCS-C) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The Youth Suicide Crisis Inventory (Y-SCI) from the Barzilay group shows particular promise for adolescents\u003csup\u003e2\u003c/sup\u003e. Additionally, although the use of an epidemiological study enhanced generalizability, the pattern of missing data introduced the possible confound of self-selection bias. Moreover, the findings may not generalize to other countries and cultures. Nonetheless, SCS in adults has shown remarkable consistency across cultures, for example, in Russia [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], Brazil [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e], and Korea [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Further, these findings, which are based upon data from 2006 to 2008, may not generalize to the present time, where social media plays such a central role in adolescent lives. This might both amplify pre-existing suicidal risk factors (e.g., sleep disturbance) and introduce new ones (e.g., cyberbullying) [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Nonetheless, we can speculate that these new circumstances might heighten the relevance of SCS among adolescents. Finally, this study did not measure the association with or prediction of suicidal behavior, gestures or death by suicide. Rather it measured lifetime SI. As noted above, while SI is far less dangerous than either suicidal behavior or death by suicide, and the characteristics of individuals with SB and who die by suicide vary to some extent [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e], SI is nonetheless an established and widely used measure of suicidal risk [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and a meaningful marker of psychological distress. As such, evidence of SCS\u0026rsquo;s association with SI can serve as a needed first step in validating the SCS among adolescents. Future research will need to assess the predictive validity of SCS in adolescents to suicidal behavior. Likewise, prior studies have shown SCS to be associated with both recent and lifetime suicidal thoughts and behavior [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. One way to understand this is that some individuals may have a propensity towards SCS, such that it recurs under stress. To the extent this is the case, education about SCS might prove a potent preventative tool.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, in the context of its limitations, the present study provides important preliminary evidence of the construct validity of Suicidal Crisis Syndrome in a community-based adolescent population. Future research can replicate and expand upon these findings, supporting the development of a potentially valuable new tool for prevention of adolescent suicide and suicide-related behavior.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSI, suicidal ideation; SCS, Suicide Crisis Syndrome; DSM-5-TR, Diagnostic and Statistical Manual for Psychiatric Disorders, 5\u003csup\u003eth\u003c/sup\u003e Edition, Text Revision; NTNU, Norwegian University of Science and Technology; HUNT, The Tr\u0026oslash;ndelag Health Study (\u003cem\u003eHelseundersokelsen i Tr\u0026oslash;ndelag\u003c/em\u003e); SCS-YHP, proxy Young-HUNT3 SCS; HSCL-5, the 5-item Hopkins Symptoms Checklist; SCI-2 Suicide Crisis Inventory, 2\u003csup\u003end\u003c/sup\u003e edition; SCS-C, the Suicide Crisis Syndrome Checklist; SCI-SF, the Suicide Crisis Inventory short form; A-SCS-C, Abbreviated Suicide Crisis Syndrome Checklist; Y-SCI, Youth Suicide Crisis Inventory.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project was approved by the Regional Committee for Medical and Health Research Ethics \u0026ndash; Southeast Norway (ref. 2018/1037) in accordance with the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants and parents of those under age 16.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability for data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe HUNT data can be accessed from the HUNT Research Centre but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. To access HUNT data, researchers must gain project approval from the Regional Committee for Medical and Health Research Ethics and submit an application to the HUNT Research Centre. Applications must be made via a collaboration with a Norwegian principal investigator. More information is available at www.ntnu.edu/hunt/data\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the American Foundation for Suicide Prevention under grant #TBT-1-136-22 (PI: Igor Galynker, MD, PhD). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIG, AEV, and ZY initiated the project, designed the study aims, selected the items for the SCS-YHP, and edited the manuscript. LJC designed and performed the data analysis, performed the literature review and wrote up the results. TF helped prepare the data set, ran the data analysis in conjunction with LJC, and reviewed the manuscript. SBE reviewed and edited the manuscript and consulted on data analysis. SK and OKD organized and extracted the relevant data from the HUNT study, reviewed the manuscript, and provided expertise on HUNT processes. BY contributed to the literature review and edited the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Suicide [Internet]. 2025. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/suicide\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/suicide\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHua LL, Lee J, Rahmandar MH, Sigel EJ. Suicide and suicide risk in adolescents. Pediatrics. 2024;153(1):1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2023-064800\u003c/span\u003e\u003cspan address=\"10.1542/peds.2023-064800\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBertuccio P, Amerio A, Grande E, La Vecchia C, Costanza A, Aguglia A et al. Global trends in youth suicide from 1990 to 2020: an analysis of data from the WHO mortality database. EClinicalMedicine. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eclinm.2024.102506\u003c/span\u003e\u003cspan address=\"10.1016/j.eclinm.2024.102506\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOur World in Data. Suicide rate, by age [Internet]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ourworldindata.org/grapher/suicide-rates-by-age-detailed-who\u003c/span\u003e\u003cspan address=\"https://ourworldindata.org/grapher/suicide-rates-by-age-detailed-who\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomer D. Adolescent risk taking, impulsivity, and brain development: Implications for prevention. Dev Psychobiol. 2010;52(3):263\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/dev.20442\u003c/span\u003e\u003cspan address=\"10.1002/dev.20442\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSisk LM, Gee DG. Stress and adolescence: vulnerability and opportunity during a sensitive window of development. Curr Opin Psychol. 2022;44:286\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.copsyc.2021.10.005\u003c/span\u003e\u003cspan address=\"10.1016/j.copsyc.2021.10.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpear LP. Heightened stress responsivity and emotional reactivity during pubertal maturation: Implications for psychopathology. Dev Psychopathol. 2009;21(1):87\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/S0954579409000066\u003c/span\u003e\u003cspan address=\"10.1017/S0954579409000066\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunstein Klomek A, Barzilay S, Apter A, Carli V, Hoven CW, Sarchiapone M, et al. Bi-directional longitudinal associations between bullying victimization, suicidal ideation/attempts, and depression. J Child Psychol Psychiatry. 2019;60(2):209\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jcpp.12951\u003c/span\u003e\u003cspan address=\"10.1111/jcpp.12951\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParellada M, Saiz P, Moreno D, Vidal J, Llorente C, Alvarez M, et al. Is attempted suicide different in adolescents and adults? Psychiatry Res. 2008;157(1\u0026ndash;3):131\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.psychres.2007.02.012\u003c/span\u003e\u003cspan address=\"10.1016/j.psychres.2007.02.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteele IH, Thrower N, Noroian P, Saleh FM. Understanding suicide across the lifespan: A United States perspective of suicide risk factors, assessment \u0026amp; management. J Forensic Sci. 2018;63(1):162\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/1556-4029.13519\u003c/span\u003e\u003cspan address=\"10.1111/1556-4029.13519\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCabezas-Klinger H, Fernandez-Daza FF, Mina-Paz Y. Associations between social media use and mental disorders in adolescents and young adults: a systematic review and meta-analysis. Behav Sci. 2025;15(11):1450. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/bs15111450\u003c/span\u003e\u003cspan address=\"10.3390/bs15111450\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarengo D, Settanni M, Mastrokoukou S, Fabris MA, Longobardi C. Social media linked to early adolescent suicidal thoughts via cyberbullying and internalizing symptoms. Int J Bullying Prev. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s42380-024-00269-y\u003c/span\u003e\u003cspan address=\"10.1007/s42380-024-00269-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilverman MM, Berman AL. Suicide risk assessment and risk formulation part I: A focus on suicide ideation in assessing suicide risk. Suicide Life Threat Behav. 2014;44(4):420\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/sltb.12065\u003c/span\u003e\u003cspan address=\"10.1111/sltb.12065\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen LJ, Imbastaro B, Peterkin D, Bloch-Elkouby S, Wolfe A, Galynker I. A suicide-specific diagnosis\u0026mdash;the case for. Crisis. 2023;44(3):175\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1027/0227-5910/a000911\u003c/span\u003e\u003cspan address=\"10.1027/0227-5910/a000911\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHallford DJ, Rusanov D, Winestone B, Kaplan R, Fuller-Tyszkiewicz M, Melvin G. Disclosure of suicidal ideation and behaviours: A systematic review and meta-analysis of prevalence. Clin Psychol Rev. 2023;101:102272. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.cpr.2023.102272\u003c/span\u003e\u003cspan address=\"10.1016/j.cpr.2023.102272\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026oslash;yen KS, Solem S, Cohen LJ, Prestmo A, Hjemdal O, Vaaler AE, et al. Non-disclosure of suicidal ideation in psychiatric inpatients: Rates and correlates. Death Stud. 2022;46(8):1823\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/07481187.2021.1879317\u003c/span\u003e\u003cspan address=\"10.1080/07481187.2021.1879317\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloch-Elkouby S, Zilcha-Mano S, Rogers ML, Park JY, Manlongat K, Krumerman M, et al. Who are the patients who deny suicidal intent? Acta psychiatrica Scandinavica. 2023;147(2):205\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/acps.13511\u003c/span\u003e\u003cspan address=\"10.1111/acps.13511\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlanchard M, Farber BA. It is never okay to talk about suicide: patients\u0026rsquo; reasons for concealing suicidal ideation in psychotherapy. Psychother Res. 2020;30(1):124\u0026ndash;36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/10503307.2018.1543977\u003c/span\u003e\u003cspan address=\"10.1080/10503307.2018.1543977\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKleiman EM, Turner BJ, Fedor S, Beale EE, Huffman JC, Nock MK. Examination of real-time fluctuations in suicidal ideation and its risk factors: Results from two ecological momentary assessment studies. J Abnorm Psychol. 2017;126(6):726\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/abn0000273\u003c/span\u003e\u003cspan address=\"10.1037/abn0000273\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeisenhammer EA, Ing CM, Strauss R, Kemmler G, Hinterhuber H, Weiss EM. The duration of the suicidal process: how much time is left for intervention? J Clin Psychiatry. 2009;70(1):19\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaashaus L, Forkmann T, Glaesmer H, Juckel G, Rath D, Sch\u0026ouml;nfelder A, et al. From decision to action: Suicidal history and time between decision to die and actual suicide attempt. Clin Psychol Psychother. 2021;28(6):1427\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/cpp.2580\u003c/span\u003e\u003cspan address=\"10.1002/cpp.2580\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloch-Elkouby S, El-Hayek R, Cohen L, Chen JP, Gorman B, Apter Y, et al. The clinician rated suicide crisis syndrome checklist (SCS-C): structure, reliability, and concurrent validity among adult psychiatric inpatients. J Affect Disord. 2026;402:121341. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jad.2026.121341\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2026.121341\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelzer L, Forkmann T, Teismann T. Suicide crisis syndrome: A systematic review. Suicide Life Threat Behav. 2024;54(3):556\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/sltb.13065\u003c/span\u003e\u003cspan address=\"10.1111/sltb.13065\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association. \u003cem\u003eDiagnostic and statistical manual of mental disorders\u003c/em\u003e. 5th ed. text rev. Washington (DC): American Psychiatric Association; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloch-Elkouby S, Gorman B, Schuck A, Barzilay S, Calati R, Cohen LJ, et al. The suicide crisis syndrome: a network analysis. J Couns Psychol. 2020;67(5):595\u0026ndash;607. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/cou0000423\u003c/span\u003e\u003cspan address=\"10.1037/cou0000423\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBafna A, Rogers ML, Galynker II. Predictive validity and symptom configuration of proposed diagnostic criteria for the suicide crisis syndrome: a replication study. J Psychiatr Res. 2022;156:228\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jpsychires.2022.10.027\u003c/span\u003e\u003cspan address=\"10.1016/j.jpsychires.2022.10.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloch-Elkouby S, Barzilay S, Gorman BS, Lawrence OC, Rogers ML, Richards J, et al. The revised suicide crisis inventory (SCI-2): validation and assessment of prospective suicidal outcomes at one month follow-up. J Affect Disord. 2021;295:1280\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jad.2021.08.048\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2021.08.048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark JY, Rogers ML, Bloch-Elkouby S, Richards JA, Lee S, Galynker I, et al. Factor structure and validation of the revised suicide crisis inventory in a Korean population. Psychiatry Investig. 2023;20(2):162\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.30773/pi.2022.0208\u003c/span\u003e\u003cspan address=\"10.30773/pi.2022.0208\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu CY, Lee JI, Lee MB, Rogers ML, Chan CT, Chen CY, et al. Identification of suicidality by five-item suicide crisis scale (SCS-5) in an online general population survey in Taiwan. J Suicidol. 2022;17(4):342\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.30126/JoS.202212_17(4).0003\u003c/span\u003e\u003cspan address=\"10.30126/JoS.202212_17(4).0003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarzilay S, Assounga K, Veras J, Beaubian C, Bloch-Elkouby S, Galynker I. Assessment of near-term risk for suicide attempts using the suicide crisis inventory. J Affect Disord. 2020;276:183\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jad.2020.06.053\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2020.06.053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYaseen ZS, Hawes M, Barzilay S, Galynker I. Predictive validity of proposed diagnostic criteria for the suicide crisis syndrome: An acute presuicidal state. Suicide Life Threat Behav. 2019;49(4):1124\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/sltb.12495\u003c/span\u003e\u003cspan address=\"10.1111/sltb.12495\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalynker I, Cohen L, Prekas AS, Bloch-Elkouby S, King M, Apter Levy Y. Suicide crisis syndrome: examining supporting evidence and barriers to diagnostic validity. Front Psychiatry. 2025;16:1627463. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyt.2025.1627463\u003c/span\u003e\u003cspan address=\"10.3389/fpsyt.2025.1627463\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarsen E, Cohen LJ, White B, De Luca GP, Goncearencoa I, Galynker II, et al. Impact of the abbreviated suicide crisis syndrome checklist on clinical decision making in the emergency department. J Clin Psychiatry. 2023;84(3):22m14655. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4088/JCP.22m14655\u003c/span\u003e\u003cspan address=\"10.4088/JCP.22m14655\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen LJ, White BJ, Miller FE, Karsen EF, Galynker II. Diagnosis of the suicide crisis syndrome in the emergency department associated with significant reduction in 3-month readmission rates. J Clin Psychiatry. 2024;85(4):24m15320. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4088/JCP.24m15320\u003c/span\u003e\u003cspan address=\"10.4088/JCP.24m15320\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsv\u0026aacute;th P, Moln\u0026aacute;r C, Lovig C, Major FN, Vencz\u0026aacute;k S, Fekete S, et al. Assessment of acute suicide risk: Opportunities for comprehensive risk evaluation in clinical practice. Orv Hetil. 2025;166(4):146\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1556/650.2025.33211\u003c/span\u003e\u003cspan address=\"10.1556/650.2025.33211\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeavey G, Rothi D, Paul R. Trust, autonomy and relationships: the help-seeking preferences of young people in secondary level schools in London (UK). J Adolesc. 2011;34(4):685\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.adolescence.2010.09.004\u003c/span\u003e\u003cspan address=\"10.1016/j.adolescence.2010.09.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHubers AAM, Moaddine S, Peersmann SHM, Stijnen T, van Duijn E, van der Mast RC, et al. Suicidal ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: A meta-analysis. Epidemiol Psychiatr Sci. 2018;27(2):186\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/S2045796016001049\u003c/span\u003e\u003cspan address=\"10.1017/S2045796016001049\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarge M, Smith G, Sharma S, Nielssen O, Singh SP. Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatr Scand. 2011;124(1):18\u0026ndash;29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1600-0447.2010.01672.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1600-0447.2010.01672.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcHugh CM, Corderoy A, Ryan CJ, Hickie IB, Large MM. Association between suicidal ideation and suicide: meta-analyses of odds ratios, sensitivity, specificity and positive predictive value. BJPsych Open. 2019;5(2):e18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1192/bjo.2018.88\u003c/span\u003e\u003cspan address=\"10.1192/bjo.2018.88\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA, Zaslavsky AM, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents. JAMA Psychiatry. 2013;70(3):1\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/2013.jamapsychiatry.55\u003c/span\u003e\u003cspan address=\"10.1001/2013.jamapsychiatry.55\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBearman PS, Moody J. Suicide and friendships among American adolescents. Am J Public Health. 2004;94(1):89\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/AJPH.94.1.89\u003c/span\u003e\u003cspan address=\"10.2105/AJPH.94.1.89\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eL\u0026oacute;pez-D\u0026iacute;az \u0026Aacute;, Palermo-Zeballos FJ, Gutierrez-Rojas L, Alameda L, Gotor-S\u0026aacute;nchez-Luengo F, Garrido-Torres N, et al. Proxy measures for the assessment of psychotic and affective symptoms in studies using electronic health records. BJPsych Open. 2024;10:e22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1192/bjo.2023.623\u003c/span\u003e\u003cspan address=\"10.1192/bjo.2023.623\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSearle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr. 2008;8(1):24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2318-8-24\u003c/span\u003e\u003cspan address=\"10.1186/1471-2318-8-24\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolmen TL, Bratberg G, Krokstad S, Langhammer A, Hveem K, Midthjell K, et al. Cohort profile of the Young-HUNT study, Norway: a population-based study of adolescents. Int J Epidemiol. 2014;43(2):536\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ije/dys232\u003c/span\u003e\u003cspan address=\"10.1093/ije/dys232\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirk\u0026oslash;en B, \u0026Oslash;rstavik RE, Reneflot A, Skogen JC, Sivertsen B, Knudsen AKS. The ability of the Hopkins Symptom Checklist-5 to identify generalized anxiety disorder and major depressive disorder in the general population. Int J Environ Res Public Health. 2025;22(5):698. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph22050698\u003c/span\u003e\u003cspan address=\"10.3390/ijerph22050698\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMonaghan TF, Rahman SN, Agudelo CW, Wein AJ, Lazar JM, Everaert K, et al. Foundational statistical principles in medical research: Sensitivity, specificity, positive predictive value, and negative predictive value. Med (Kaunas). 2021;57(5):503. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/medicina57050503\u003c/span\u003e\u003cspan address=\"10.3390/medicina57050503\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBil\u0026eacute;n K, Ponzer S, Ottosson C, Castr\u0026eacute;n M, Pettersson H. Deliberate self-harm patients in the emergency department: who will repeat and who will not? Emerg Med J. 2013;30(8):650\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/emermed-2012-201235\u003c/span\u003e\u003cspan address=\"10.1136/emermed-2012-201235\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteeg S, Kapur N, Webb R, Applegate E, Stewart SLK, Hawton K, et al. The development of a population-level clinical screening tool for self-harm repetition and suicide: The ReACT self-harm rule. Psychol Med. 2012;42(11):2383\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/S0033291712000347\u003c/span\u003e\u003cspan address=\"10.1017/S0033291712000347\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogers ML, McMullen L, Liang Y, Perez N, Richards JA, Ak\u0026uuml;lker G, et al. Cross-national presence and sociodemographic correlates of the suicide crisis syndrome. J Affect Disord. 2023;329:1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jad.2023.02.076\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2023.02.076\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnne E. Casey Foundation. Youth mental health statistics. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aecf.org/blog/youth-mental-health-statistics\u003c/span\u003e\u003cspan address=\"https://www.aecf.org/blog/youth-mental-health-statistics\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 24 Mar 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. Data and statistics on children\u0026rsquo;s mental health. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/children-mental-health/data-research/index.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/children-mental-health/data-research/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 24 Mar 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHusky MM, L\u0026eacute;on C, Vasiliadis HM. Increases in suicidal thoughts disclosure among adults in France from 2000 to 2021. J Affect Disord. 2025;371:54\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jad.2024.11.042\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2024.11.042\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarhane-Medina NZ, Luque B, Tabernero C, Castillo-May\u0026eacute;n R. Factors associated with gender and sex differences in anxiety prevalence and comorbidity: A systematic review. Sci Prog. 2022;105(4):368504221135469. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/00368504221135469\u003c/span\u003e\u003cspan address=\"10.1177/00368504221135469\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMagovcevic M, Addis ME. The masculine depression scale: Development and psychometric evaluation. Psychol Men Masc. 2008;9(3):117\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/1524-9220.9.3.117\u003c/span\u003e\u003cspan address=\"10.1037/1524-9220.9.3.117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Luca GP, Parghi N, El Hayek R, Bloch-Elkouby S, Peterkin D, Wolfe A, et al. Machine learning approach for the development of a crucial tool in suicide prevention: The Suicide Crisis Inventory-2 (SCI-2) short form. PLoS ONE. 2024;19(5):e0299048. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0299048\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0299048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026oslash;yen KS, Cohen LJ, Solem S, Prestmo A, S\u0026oslash;rensen K, Salvesen \u0026Oslash;, et al. Exploring associations between the MARIS questionnaire and recent suicidal ideation and behavior among patients admitted at an acute psychiatric inpatient department. Nord J Psychiatry. 2023;77(3):266\u0026ndash;75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/08039488.2022.2100929\u003c/span\u003e\u003cspan address=\"10.1080/08039488.2022.2100929\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChistopolskaya KA, Rogers ML, Enikolopov SN, Kravtsova NA, Sadovnichaya V, Drovosekov S. Adaptation of the suicide crisis inventory (SCI-2) in a Russian internet sample during the COVID-19 epidemic. Suicidology Russia. 2022;13:88\u0026ndash;104. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.32878/suiciderus.22-13-01(46)-88-104\u003c/span\u003e\u003cspan address=\"10.32878/suiciderus.22-13-01(46)-88-104\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeper-Nascimento J, Rogers ML, Richards JA, Diaz AP, Ceretta LB, Keller GS, et al. Suicide crisis inventory-2: factor structure, internal consistency, and validity in a Brazilian sample. Rev Bras Psiquiatr. 2024;46:e20233366. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.47626/1516-4446-2023-3366\u003c/span\u003e\u003cspan address=\"10.47626/1516-4446-2023-3366\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaycox LH, Murphy ER, Zehr JL, Pearson JL, Avenevoli S. Social media and suicide risk in youth. JAMA Netw Open. 2024;7(10):e2441499. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2024.41499\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2024.41499\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiao Y, Bi K, Yip PSF, Cerel J, Brown TT, Peng Y, et al. Decoding suicide decedent profiles and signs of suicidal intent using latent class analysis. JAMA Psychiatry. 2024;81(6):595. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamapsychiatry.2024.0171\u003c/span\u003e\u003cspan address=\"10.1001/jamapsychiatry.2024.0171\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen LJ, Ardalan F, Yaseen Z, Galynker I. Suicide crisis syndrome mediates the relationship between long-term risk factors and lifetime suicidal phenomena. Suicide Life-Threatening Behav. 2018;48(5):613\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/sltb.12387\u003c/span\u003e\u003cspan address=\"10.1111/sltb.12387\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Cohen LJ, Vaaler A, Yaseen Z, H\u0026oslash;yen K, Galynker I. SCS proxy measure predicts future deliberate self-harm and death by suicide in a population-wide survey study. Unpublished manuscript; 2026.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Barzilay S. Suicide Crisis Syndrome-based adaptive screening in adolescents. Presented at: International Summit on Suicide Research; 2025 Nov 8\u0026ndash;11; Boston, MA, United States.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Suicide, risk assessment, Suicide Crisis Syndrome, HUNT study, adolescents, suicidal ideation","lastPublishedDoi":"10.21203/rs.3.rs-9473762/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9473762/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSuicide among youth has increased over past decades and is now among the most common causes of death for adolesecents. Suicidal ideation, the traditional basis of risk assessment, has serious limitations in predicting imminent risk, necessitating novel modes of risk assessment. The Suicide Crisis Syndrome (SCS) is an acute cognitive-affective state that has been shown to be predictive of near-term suicidal thoughts and behavior. It is currently under consideration for inclusion in DSM as a suicide-specific disorder. To date, the SCS has not been tested in adolescents. The present study examines the concurrent validity of the SCS with regard to suicidal ideation using data from an epidemiological study of adolecent health, the Norwegian Young-HUNT3 study.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe sample included 8,199 adolescents, aged 13\u0026ndash;20, who participated in the Young HUNT3 study, administered between 2006 and 2008 in the Tr\u0026oslash;ndelag district of Norway. Of these, 3,212 respondents answered a question on history of suicidal ideation. The SCS was assessed by a proxy measure (SCS-YHP) derived from the survey items. The association between the SCS-YHP and suicidal ideation was assessed through several logistic regression analyses. Sensitivity analyses were performed to test two additional formats of the SCS-YHP, maintaining the same items but reducing the stringency of the criteria to increase the case rate.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eConcurrent validity was strong for all three formats. Odds ratios ranged from 6.72 to 11.75 and were significant, at minimum, at the .002 level, such that adolescents who were rated as SCS positive, by any of 3 different formats, were approximately 7\u0026ndash;12 times more likely to report a history of suicidal ideation. These associations remained significant after controlling for age and sex. Sensitivity and specificity were also high; 67 to 78% for sensitivity and 77\u0026ndash;78% for specificity across the three formats, the most stringent format having the strongest sensitivity/specificity.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAs an important first step, this study provides prelmimary evidence of concurrent validity for the Suicide Crisis Syndrome among adolescents. Future research can aim to replicate these findings with a validated measure of the SCS for youth and to test predictive validity to suicidal behavior.\u003c/p\u003e","manuscriptTitle":"The Relationship Between the Suicide Crisis Syndrome and Suicidal Ideation in Adolescents: A Preliminary Validation Study Using Data from the Young-HUNT3 epidemiological study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 18:04:37","doi":"10.21203/rs.3.rs-9473762/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-04T08:33:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T08:47:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16340381354431932147750120729734129598","date":"2026-04-30T16:01:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270450828302649014007874410220569933163","date":"2026-04-30T16:00:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-30T15:52:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-22T15:01:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-22T09:09:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-22T09:09:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2026-04-20T14:23:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"27be0f4b-fdf5-43c6-930f-3691b989aa6a","owner":[],"postedDate":"May 8th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-04T08:33:43+00:00","index":28,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T08:47:16+00:00","index":27,"fulltext":""},{"type":"reviewerAgreed","content":"16340381354431932147750120729734129598","date":"2026-04-30T16:01:27+00:00","index":25,"fulltext":""},{"type":"reviewerAgreed","content":"270450828302649014007874410220569933163","date":"2026-04-30T16:00:33+00:00","index":24,"fulltext":""},{"type":"reviewersInvited","content":"3","date":"2026-04-30T15:52:03+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T18:04:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-08 18:04:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9473762","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9473762","identity":"rs-9473762","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}