Original article [612460]

Original article
Suicidal Adolescents ’Experiences With Bullying Perpetration and
Victimization during High School as Risk Factors for Later Depression
and Suicidality
Anat Brunstein Klomek, Ph.D.b,c, Marjorie Kleinman, M.S.b, Elizabeth Altschuler, M.A.b,
Frank Marrocco, Ph.D.a, Lia Amakawa, M.A.b, and Madelyn S. Gould, Ph.D., M.P.H.a,b,*
aDivision of Child Psychiatry and Department of Epidemiology, Columbia University, New York, New York
bNew York State Psychiatric Institute (NYSPI), New York, New York
cSchool of Psychology, Interdisciplinary Center (IDC), Herzliya, Israel
Article history: Received June 7, 2012; Accepted December 11, 2012
Keywords: Bullying; Victimization; Adolescents; Suicide; High school
ABSTRACT
This is the first study to examine the extent to which frequent involvement in high-school bullying (as
a bullying perpetrator, victim of bullying, or bully-victim) increases the risk for later depression and sui-
cidality beyond other well-established risk factors of suicide. The study included 96 students who reported
being a bully, a victim, or a bully-victim, and also reported depression, suicidality, or substance problems
during an initial suicide screen. These students were interviewed 2 years later and were compared with 142
youth identi fied during the initial screen as “suicide-at-risk ”by virtue of their depression, suicidal ideation,
attempts, and substance problems, but who did not report any involvement in bullying behavior. Student: [anonimizat], especially the frequent bullies.
/C2112013 Society for Adolescent Health and Medicine.
In the United States, Nansel et al. [1]have found that 8.8% of
sixth to tenth grade students admitted to bullying others oncea week or more, while 8.4% have experienced bullying once a week
or more. In a typical 12-month period nearly 14% of American high
school students seriously consider suicide while 6.3% actually
attempt suicide [2]. Most of the literature on the association
between bullying and suicidality is based on cross-sectionalstudies. The few longitudinal studies of bullying behavior and
later depression or suicidal ideation and behavior that exist havereported con flicting findings. A study in Norway [3]reported that
those being seriously bullied at age 11 years suffered from “bouts of
depression ”as young adults. A study in Australia [4]reported that
victimization in the eighth year of secondary school was associatedwith newly incident symptoms of depression the following year.
However, a follow-up study of Finnish children involved in bullying
at the age of 8 or 12 years indicated that when psychiatric symp-
toms were taken into account, involvement in bullying did not
independently increase the likelihood of depressive symptoms at
age 15 years [5]. Similarly, a 2-year follow-up of peer victimization
among high school students in Australia, found that victimizationat baseline was not predictive of “psychiatric health ”after baseline
health status was taken into account [6].
As for the effects of bullying behavior on later suicidality and
self-harm, Barker et al. [7]have found that youth reporting both
high and increasing levels of bullying perpetration and increasing
levels of victimization had the highest rates of self-harm at a
3-year follow-up. Kim et al. [8]have reported that adolescentsThe authors declare no confl icts of interest.
Publication of this article was supported by the Centers for Disease Control and
Prevention. The opinions or views expressed in this paper are those of the
authors and do not necessarily represent the of ficial position of the Centers for
Disease Control and Prevention.
*Address correspondence to: Madelyn S. Gould, Ph.D., M.P.H., NYSPI, 1051
Riverside Dr., New York, NY 10032.
E-mail address: gouldm@childpsych.columbia.edu (M.S. Gould).www.jahonline.org
1054-139X /C2112013 Society for Adolescent Health and Medicine.
http://dx.doi.org/10.1016/j.jadohealth.2012.12.008Journal of Adolescent Health 53 (2013) S37 eS42
Open access under CC BY-NC-ND license.
Open access under CC BY-NC-ND license.

involved in bullying, especially those who both bullied others
and were victims of bullying (bully-victims), victims only, girls
who bully, and boys with later onset bullying behaviors were at
increased risk for suicidal/self-injurious behaviors and ideation
at a 10-month follow-up, even after controlling for other suicide
risk factors. A study of Finnish boys, however, found that bullying
behavior at age 8 years was not associated with suicidal ideation
10 years later when controlling for childhood depression [9].I n
addition, frequent bullying and victimization among boys werenot associated with later suicide attempts and completed suicide
after controlling for conduct and depression symptoms. Frequent
victimization among girls, however, was associated with later
suicide attempts and completed suicides, even after controlling
for conduct and depression symptoms [10]. Another recent study
[11]indicated that students who only reported frequent bullying
behaviors in high school (no depression or suicidality at baseline)
did not develop later depression or suicidality and continued to
have fewer psychiatric problems than students identi fied as
at-risk for suicide at baseline.
The current study adds to the longitudinal evidence that
is necessary to establish causality in the association betweenbullying and suicidality. Moreover, it focuses on high school bullying
and differentiates students who were perpetrators of bullying,
victims of bullying, and both (bully-victims). The aim of the current
study is to examine the extent to which bullying involvement in high
school increases the risk for later depression and suicidality beyond
the risk derived from other well-known risk factors, such as
depression, serious suicidal ideation, and a previous suicide attempt.
Methodology
Participants
Adolescents aged 13 through 18 years, enrolled in ninth through
twelfth grade in six high schools in Nassau, Suffolk, and West-
chester counties in New York State, were the targeted population
for the suicide screening project from which the cohorts for the
present project were identi fied. Five schools were public coed
schools and one was a parochial all-boys school. We assessed 2,342of 3,635 students (64.4% participation rate) from 2002 through
2004. Reasons for nonparticipation included parent refusals
(61.9%), student refusals (14.3%), and absences (23.7%). The ethnic
distribution of the participating sample was 80.3% white, 5.1%
African-American, 7.3% Hispanic, 3.8% Asian, and 3.5% other; 58.1%
of the students were male. The inclusion of an all-male parochial
school explains the high percentage of boys. The average age of
participating students was 14.8 years ( /C61.2 sd). There were no
significant differences between participants and nonparticipants
in gender, age, and ethnicity [see Reference 12for details].
Measures
The same measures were used in screening and follow-up
assessments, with the exception of the bullying measure, which
was used only at baseline. Self-completion screening question-
naires were completed by the students over two class periods, on
separate days (described in detail in Reference 12). The follow-up
measures were administered in an interview format via tele-
phone. Use of self-reports followed by a safety interview with
a health professional is common in the field of suicide screening to
enhance the safety of the individuals [13,14] .Beck Depression Inventory (BDI-IA). The BDI-IA [15] contains 21
items that assess cognitive, behavioral, affective, and somaticcomponents of depression. Loss of libido was not assessed. The
responses for each question range from 0 (the depressive
symptom is not present) to 3 (the symptom is severe). The BDI
has demonstrated excellent internal consistency and good
test-retest reliability in research in adolescents and excellent
sensitivity and speci ficity in identifying major depression in
adolescents [16,17] .
Suicidal Ideation Questionnaire (SIQ-JR). The 15-item SIQ-JR [18]
uses a seven-point Likert-type scale, ranging from 0 ( “I never had
this thought ”) to 6 ("This thought was in my mind almost every
day"), assessing the frequency of speci ficsu
icidal thoughts during
the past month. It assesses awide range of thoughts related to deathand dying, passive and active suicidal ideation, and suicidal intent.
Reliability and validity of the SIQ-JR are well-documented [19].
Suicide attempt history. Seven questions asking about lifetime
and recent suicide attempts were derived from the depression
module of the Diagnostic Interview Schedule for Children (DISC-
IV)[20] and an earlier suicide screen [14]. These items have
demonstrated good construct validity [14]. The assessment of an
attempt included questions about occurrences, injuries sus-
tained, medical care sought, and hospitalization.
Drug Use Screening Inventory (DUSI). The DUSI [21,22] is
designed to screen for alcohol or drug use and problems among
teenagers, and has demonstrated good reliability, discriminant
validity and sensitivity, and has published normative cutoff
scores [21e24]. A total score combines all 15 items from the
substance-use scale (assessing the degree of involvement andseverity of consequences from alcohol and drug use), three
alcohol or drug items on the school performance adjustment
scale, and one additional aggression item assessing the clinically
predictive problem of breaking things or getting into fights while
under the in fluence of alcohol or drugs [25].
Columbia Impairment Scale (CIS). The CIS provides a measure of
overall severity of functional impairment [26]. It is a 13-item
scale tapping four major areas of functioning: interpersonalrelationships, school/work, certain broad areas of psychopa-
thology (general behavior or mood), and use of leisure time. The
CIS has demonstrated good internal consistency, test-retest
reliability, and discriminant validity [26].
Bullying/Bullied experiences. Several questions regarding
bullying behavior were derived from the World Health Organi-zation study on youth health [1]. The subject was introduced as
follows: “The next 7 questions are about bullying. We say
a student is being bullied when another student, or group ofstudents, says or does nasty and unpleasant things to him or her.
It is also bullying when a pupil is teased repeatedly in a way he or
she doesn’ t like. But it is not bullying when two students of about
the same strength quarrel or fight. ”Separate questions assessed
the frequencies of bullying and being bullied at school and away
from school property. Additional questions asked students to
report the frequency with which they were bullied in each of
seven ways (Made fun of you because of your religion or race;
Made fun of you because of your looks or speech; Hit, slapped, or
punched you; Spread rumors or mean lies about you; Made
sexual jokes, comments, or gestures to you; Used e-mail orA.B. Klomek et al. / Journal of Adolescent Health 53 (2013) S37 eS42 S38

Internet to be mean to you). The items were coded on a five-point
scale from (0) “not at all ”to (4) “most days ”. Frequent bullying
and being bullied was de fined as once a week or more [1]. This
scale had high reliability in the current study (Cronbach a¼.79).
Procedures
Standard risk indicators from the initial screen were used to
identify an at-risk cohort of youth reporting in the self-report
questionnaires recent or past suicidal behavior, prominent
current suicidal ideation, moderate to severe depression, and/or
substance abuse impairment [12,27] . For adolescents reporting
serious suicidal ideation, past suicide attempt, depression withany level of suicidal ideation, or requesting to talk to a clinician,
a“Safety Review ”interview was conducted by a project child
psychiatrist, psychologist, or social worker. The project’ s clinical
team interviewed these adolescents to assess imminent suicide
risk and the need for further evaluation and treatment. If survey
responses were substantiated during the interview, a project
social worker contacted the parents by telephone to providea summary of the screening results, verify a student ’s report of
current treatment, and discuss recommendations for furtherevaluation and treatment with a local mental health provider.
Because most youth with depression and substance abuse
problems do not engage in suicidal behavior, those who scored
above the cutoff on the problem scales, without reporting
current suicidal ideation or history of attempts, were not inter-
viewed by our project’ s clinical team; however, project social
workers noti fied their parents of the survey findings.
A total of 317 students were identi fied as at risk for suicide
[28]. Among the suicide-at-risk cohort, 96 students reported
frequent bullying behavior (41 as “Suicide-At-Risk Bully Perpe-
trators, ”42 as “Suicide-At-Risk Victims of Bullying, ”and 13 as
“Suicide-At-Risk Bully-Victims ”) during the screen. The remain-
ing 221 individuals ( “Suicide-At-Risk only ”group) reported
suicide-related behaviors but did not report frequent bullying/
victimization behavior (see Figure 1 ).
On the parent information sheet and student assent form of
our originating study [12], we indicated the possibility of a future
follow-up. For the current project, we first approached the
youths ’parents by mail and asked them to forward our recruit-
ment letter to the youth. Only if the youth was older than 18years of age did we approach them directly by mail.
Only 62% of eligible subjects participated in the follow-up
study, but we found no demographic or baseline clinical differ-
ences between participants and nonparticipants. Approximately2 years after the initial screen, a follow-up telephone interviewwas conducted with the youth, including 24 of the Suicide-At-
Risk Bully Perpetrator group, 20 of the Suicide-At-Risk Victim
of Bullying group, 10 of the Suicide-At-Risk Bully-Victim Group,
and 142 of the Suicide-At-Risk only group.
Active consent from the parents and assent from the youth (or
consent, depending on age of participant) was obtained via the
telephone before the follow-up telephone interview proceeded.
The average length of the interview was 45 minutes. Con fiden-
tiality issues were handled according to standard clinical ethics.The youth was informed before the survey that serious suicide
ideation or suicidal behavior would be shared with their parents.
If in the course of the follow-up interview, the youth indicated
that he/she may be in danger of harming him/herself the parent
was noti fied and the interviewer immediately noti fiedour
pr
oject clinician (A.B.K.). The clinician would then contact the
youth to assess the immediacy of the problem and contacted theparents if the youth was in danger of harming him/herself. In all
these cases, a list of community providers and mental health
centers was mailed. The study procedures were approved by the
institutional review board of the New York State Psychiatric
Institute/Columbia University Department of Psychiatry.
Definition of at-risk status
A youth was determined to be “Suicide-At-Risk ”[12,28] from
the baseline screen if he/she (1) reported serious suicidal ideation
as operationalized by a score greater than or equal to 31 on the SIQ-
JR; or an endorsement of any of six SIQ-JR “critical items ”at the
clinically signi ficant levels of “a couple of times a week ”or“almost
every day” (“I thought about killing myself ”;“I thought about how I
would kill myself ”;“I thought about when I would kill myself ”;“I
thought about what to write in a suicide note ”;“I thought about
writing a will ”;“I thought about telling people I had a plan to kill
myself ”); oran endorsementof BDI item statements “I would like to
kill myself ”or“I would kill myself if I had a chance ”; (2) endorsed
a past suicide attempt (regardless of timing, injury or medicalattention); (3) exhibited depression as de fined by a BDI score
greater than or equal to 16; or (4) reported a substance problem, asmanifested by an endorsement of four out of eight clinically
significant impairment items on the DUSI [12]. These risk criteria
were based on those identi fied in studies of youth suicide [29].
Data analysis
Psychiatric status outcomes are depression (BDI), suicidal
ideation (SIQ-JR), suicide attempts, substance use impairment
Figure 1. Description of sample, showing rates of participation in follow-up.A.B. Klomek et al. / Journal of Adolescent Health 53 (2013) S37 eS42 S39

(DUSI), and functional impairment reported by the youth (CIS-Y).
With the exception of history of suicide attempts, the outcomes
were used as continuous variables.
For the baseline and follow-up contrasts, all continuous
outcomes and the one dichotomous outcome (history of suicide
attempts) were examined by use of a series of independent
t-tests and chi-square analyses with the continuity correction,
respectively. Longitudinal analyses used a series of t-tests for
dependent samples for the continuous variables and McNemar
chi-square test for the dichotomous variable. The follow-up
participants were employed in all analyses (including the base-
line comparisons).
Results
Baseline characteristics of follow-up participants were not
different between the bullying groups (bully, victim, bully-
victim) ( Table 1 ). A total of eight students made a suicide
attempt during the 2-year follow-up (six were from the “Suicide-
At-Risk Only ”group, one from the “Suicide-At-Risk Bully
Perpetration ”group and one from the “Suicide-At-Risk Victim of
Bullying” group).
Psychiatric problems at baseline
Students who had risk factors for suicide in high school but
were not involved in bullying behavior ( “Suicide-At-Risk Only ”
group) had signi ficantly lower levels of substance problems and
functional impairment compared with students who had thesuicide-related risk factors and were also bullies ( “Suicide-At-
Risk Bully Perpetrator ”group) ( Table 2 ) (Substance problems: 2.7
vs. 5.4 respectively, p<.01; Functional impairment: 14.8 vs. 21.5,
p<.001). There were no statistically signi ficant differences
between the “Suicide-At-Risk Only ”group and the “Suicide-At-
Risk Victims of Bullying” group. The “Suicide-At-Risk Only ”
group had signi ficantly lower levels of depression, suicidal
ideation, and functional impairment than the “Suicide At-Risk
Bully-Victim ”group (Depression: 18.5 vs. 24.8, p<.01; Suicide
ideation: 20.6 vs. 35, p<.05; Functional impairment: 14.8 vs.
23.2, p<.01).
A comparison of the at-risk bullying groups ( “Suicide-At-Risk
Bully Perpetrator ”group, “Suicide-At-Risk Victims of Bullying ”
grou p,
and “Suicide-At-Risk Bully-Victim ”group) indicated that
the groups were not signi ficantly different in terms of depres-
sion, suicidal ideation, substance problems, and functional
impairment.
Psychiatric problems at follow-up
The “Suicide-At-Risk Only ”group had lower levels of suicidal
ideation and functional impairment compared with the “Suicide-
At-Risk Bully Perpetration ”group ( Table 3 ) (Suicide ideation: 8.5
vs. 13.9 respectively, p<.05; Functional impairment: 6.3 vs. 11.3
respectively, p<.01). These students also had lower levels of
depression and substance problems, but these were not statis-
tically signi ficant (although depression was approaching signif-
icant difference). There were no statistically signi ficant
differences between the “Suicide-At-Risk Only ”group and the
“Suicide-At-Risk Victim of Bullying ”group. Similarly, there were
no statistically signi ficant differences between the “Suicide-At-
Risk Only ”group and the “Suicide-At-Risk Bully-Victim ”group,
but this finding should be considered with caution because the
number of youth in this last group was small.
Comparisons between the suicide-at-risk bully groups (“ At-
Risk Bully Perpetrator, ”“At-Risk Victim of Bullying, ”“At-Risk
Bully-Victim ”) indicated that the students who were bullying
others in conjunction with other risks in high school (e.g.,depression) were signi ficantly more likely to be functionally
impaired later compared with at-risk students who were victimsof bullying in high school (11.3 vs. 6.5 respectively, p<.05).
Discussion
To our knowledge, this is the first study to examine whether
high school students who screen positive for both bullyingbehavior (as a bully perpetrator, a victim of bullying, orTable 1
Baseline characteristics of follow-up participants
Suicide-At-Risk Only
N¼142Suicide-At-
Risk & Bully
Perpetrator
N¼24Suicide-At-Risk &
Victim of
BullyingN¼20Suicide-At-Risk &
Bully-Victim
N¼10
Age mean, sd 15.1, 1.2 15.1, 1.3 14.9, 1 14.7, 1.3Sex n, %
Male 50, 35.2 9, 37.5 7, 35 4, 40
Female 92, 64.8 15, 62.5 13, 65 6, 60
Ethnicity n, %
White 111, 78.2 21, 87.5 15, 75 10, 100African-
American5, 3.5 1, 4.2 1, 5 0, 0
Hispanic 16, 11.3 1, 4.2 3, 15 0, 0Asian 5, 3.5 1, 4.2 0, 0 0, 0
Other 5, 3.5 0, 0 1, 5 0, 0
Table 2
Psychiatric problems at baseline by at-risk and bully status for participants in follow-up
Suicide-At-Risk OnlyN¼142Suicide-At-Risk &Bully Perpetrator
N¼24Suicide-At-Risk &
Victim of Bullying
N¼20Suicide-At-Risk &
Bully-Victim
N¼10
Dichotomous measures N, %
Attempts 43, 30.3 10, 41.7 4, 20 4, 40
Continuous measures mean, sd
Depression 18.5, 7.2
c21.6, 9 20.7, 6.4 24.8, 5.7c
Suicide ideation 20.6, 16.1e26.4, 19.8 21.9, 12.3 35, 26.9e
Substance problem 2.7, 3.5b5.4, 5.9b2.7, 3.1 3.5, 3.8
Functional impairment 14.8, 8.2a,d21.5, 8.1a17.1,8.3 23.2, 7.3d
aBaseline contrast between the “suicide-at-risk only ”and “suicide-at-risk bully perpetrator ”groups is signi ficant at p<.001.
b,c,dBaseline contrast between the “suicide-at-risk only ”and “suicide-at-risk bully perpetrator ”groups or “suicide-at-risk bully-victim ”groups is signifi cant at p<.01
eBaseline contrast between the “suicide-at-risk only ”and “suicide-at-risk bully-victim ”groups is signifi cant at p<.05.A.B. Klomek et al. / Journal of Adolescent Health 53 (2013) S37 eS42 S40

bully-victim) and for risks for suicide, including depression,
suicidal ideation/behavior, and substance problems, are at
increased risk for later depression and suicidality compared with
students who only exhibit these other risk factors for suicide. The
main finding of this study is that students who perpetrated
bullying in conjunction with problems warranting their meeting
the suicidal risk threshold in high school were the most likely to
experience psychiatric problems at follow-up. Approximately
2 years after the initial assessment psychological problems were
still less frequent among those who had only reported risks for
suicidal behavior (based on suicidal ideation, suicidal behavior,
depression, or substance abuse) compared with students who
had the suicide-related risk factors but also reported perpe-
trating bullying. This implies that frequent bullying of others
during high-school years increases the risk for later depression
and suicidality above and beyond the other established risk
factors of suicide. The finding strengthens bullying as an
important risk factor that should be considered among otherimportant risk factors.
We found no signi ficant difference between bully-victims
who were at risk by virtue of their depression, suicidality, or
substance problems in high school and those who shared these
risks, but were neither bullies nor victims. However, this finding
probably refl ects the small number of “Suicide-At-Risk Bully-
Victims ”in the sample.
Ourfindings are consistent with a study by Rigby [6]among
Australian youth, which found that victimization at baseline was
not predictive of later “psychiatric health” after baseline health
status was taken into account. Our findings are also consistent
with Kim et al. [30], who demonstrated that bullying (and not
only victimization) is a strong risk factor for the later develop-
ment of psychopathologic behaviors. However, our findings are
not consistent with those of Skapinakis [31] who found that
victims of bullying behavior were more likely to express suicidal
ideation. Their association was particularly strong for those who
were bullied on a weekly basis and it was independent of the
presence of psychiatric morbidity. In contrast, being a perpe-
trator was not associated with this type of ideation after
adjustment. The differences between our results and those of
Skapinakis may be explained by the fact that Skapinakis ’s study
was cross-sectional and assessed as outcome the least severeform of suicidal ideation, whereas we assessed serious suicidal
ideation in a longitudinal study.
Ourfindings, which emphasize the concern for those high
school students who bully others, support previous studies
indicating that externalizing behavior is an important psychiatriccorrelate of depression and suicidal behavior. Aggression may
even be as important as depression in some kind of suicidal
behaviors [32]. Apter et al. [33] have argued that suicide risk
among individuals with externalizing disorders may be related toimpulsive and anger-related behaviors.
The longitudinal design is a major strength of the study,
providing a more valid examination of the independent sequelae
of bullying behavior than cross-sectional data can provide.
However, the study has several limitations. First, at baseline we
used self-report questionnaires while at follow-up we conducted
a telephone interview. Studies have shown that there are
differences between alternative modes of assessing depression
and suicidality [34,35] . People tend to disclose more on self-
reports [36].Nev
ertheless, identical procedures were used for
all groups, so the data collection procedures would not have an
impact on our examination of group differences. Second,
although we included questions about speci fic types of victimi-
zation (e.g., cyberbullying), we were unable to examine theirimpact separately due to small sample sizes. Third, we employed
suburban schools with predominantly white populations of
limited socioeconomic diversity because the sampling frame was
dictated by design considerations of our earlier study [12].A s
such, the results cannot be generalized to urban, more ethnicallyor socioeconomically diverse settings. Previous studies reporting
on ethnicity and socioeconomic status as factors in bullying
behavior have shown inconsistent results [1,37e40]. Fourth,
information about bullying behavior is based only on self-reports. Future studies may want to include peer nomination
or parent/teacher reports. Fifth, we did not have measures of
other established risk factors (e.g., impulsive aggression, sexualabuse, sexual orientation, suicide in the family) and thus cannot
be certain whether it is bullying speci fically that is relevant, or
just the addition of one more major risk factor. Sixth, only 62% ofeligible subjects completed follow-up assessments. Although
those with poor emotional health are less likely to participate in
a follow-up, we did not find the differences between the
participants and nonparticipants to be clinically or statisticallysignificant. For example, 78.6%, 25%, 29.6%., 27.8%, 44.8% of the
participants’ responses during the screen indicated that they
were depressed, had serious suicidal ideation, had attempted
suicide, had a substance problem, or were functionally impaired,
respectively; whereas, 83%, 29.8%, 27.7%, 18.1%, 47.9% of the
nonparticipants’ responses indicated that they were depressed,
had serious suicidal ideation, had attempted suicide, hada substance problem, or were functionally impaired, respectively
[28]. Lastly, bullying related behaviors were not measured atTable 3
Psychiatric problems at follow-up by at-risk and bully status for participants in follow-up
Suicide-At-Risk OnlyN¼142Suicide-At-Risk &Bully PerpetratorN¼24Suicide-At-Risk &Victim of BullyingN¼20Suicide-At-Risk &Bully-VictimN¼10
Dichotomous measures N, %
Attempts 6, 4.2 1, 4.2 1, 5 0
Continuous measures mean, sd
Depression 9.7, 6.8 12.5, 10.3 9.4, 6.4 12, 7.2
Suicide ideation 8.5, 8.1
a13.9, 15.4a8.3, 9.5 8, 6.7
Substance problem 1.8, 2.6 2.7, 3.2 1.6, 2.2 1.4, 2.3
Functional impairment 6.3, 6.3b11.3, 8.6b,c6.5, 4.3c7.8, 9.1
aContrast between the “suicide-at-risk only ”and “suicide-at-risk bully perpetrator ”groups is signi ficant at p<.05.
bContrast between the “suicide-at-risk only ”and “suicide-at-risk bully perpetrator ”groups is signi ficant at p<.01.
cContrast between the “suicide-at-risk bully perpetrator ”and “suicide-at-risk victim of bulling ”groups is signi ficant at p<.05.A.B. Klomek et al. / Journal of Adolescent Health 53 (2013) S37 eS42 S41

follow-up so it is possible, for example, that bullying behaviors
continued for the perpetrators but did not for the victims.
In summary, bullying others in conjunction with depression
or suicidality in high school is indicative of more serious
concurrent problems and portends a worse outcome 2 years later
than exhibiting depression or suicidality only. Thus, an assess-
ment of bullying behaviors should be considered in suicide
screening protocols. In addition, programs designed to reduce
bullying behavior should be concerned with bullies as well as
victims. Preventive efforts in high school should include those
children who are characterized by both psychological distur-
bance and bullying, especially those who bully others.
Acknowledgments
The project was supported by the CDC grant R49 CE000258
and NIMH grant R01-MH64632.
References
[1] Nansel TR, Overpeck M, Pilla RS, et al. Bullying behaviors among U.S. youth:
prevalence and association with psychosocial adjustment. JAMA 2001;285:
2094e100.
[2] Centers for Disease Control and Prevention. Youth risk behavior surveil-
lancedUnited States, 2009. Surveillance summaries. Morbidity and
Mortality Weekly Report 2010;59(SS-5).
[3] Olweus D. Victimization by peers: Antecedents and long-term outcomes.
In: Rubin KH, Asendorf JB, editors. Social withdrawal, inhibition and
shyness in children. Hillsdale, NJ: Erlbaum; 1992:315 e41.
[4] Bond L, Carlin JB, Thomas L, et al. Does bullying cause emotional problems?
A prospective study of young teenagers. BMJ 2001;323:480 e4.
[5] Kumpulainen K, Rasanen E. Children involved in bullying at elementary
school age: Their psychiatric symptoms and deviance in adolescence. Anepidemiological sample. Child Abuse Negl 2000;24:1567 e77.
[6] Rigby K. Peer victimization at school and the health of secondary school
students. Br J Educ Psychol 1999;69:95 e104.
[7] Barker ED, Arseneault L, Brendgen M, et al. Joint development of bullying
and victimization in adolescence: Relations to delinquency and self-harm.J Am Acad Child Adolesc Psychiatry 2008;47:1030 e8.
[8] Kim YS, Leventhal BL, Koh YJ, et al. Bullying increased suicide risk:
Prospective study of Korean adolescents. Arch Suicide Res 2009;13:15 e30.
[9] Klomek AB, Sourander A, Kumpulainen K, et al. Childhood bullying as a risk
for later depression and suicidal ideation among Finnish males. J Affect
Disord 2008;109:47 e55.
[10] Klomek AB, Sourander A, Niemela S, et al. Childhood bullying behaviors as
a risk for suicide attempts and completed suicides: A population-basedbirth cohort study. J Am Acad Child Adolesc Psychiatry 2009;48:254 e61.
[11] Klomek AB, Kleinman M, Altschuler E, et al. High school bullying as a risk
for later depression and suicidality. Suicide Life Threat Behav 2011;41:501e16.
[12] Gould MS, Marrocco FA, Kleinman M, et al. Evaluating iatrogenic risk of
youth suicide screening programs: A randomized controlled trial. JAMA
2005;293:1635 e43.
[13] Gutierrez MP, Osman A. Getting the best return on your screening
investment: An analysis of the Suicide Ideation Questionnaire and the
Reynolds Depression Rating Scale. School Psychol Rev 2009;2:200 e17.
[14] Shaffer D, Scott M, Wilcox H, et al. The Columbia Suicide Screen: Validity
and reliability of a screen for youth suicide and depression. J Am Acad ChildAdolesc Psychiatry 2004;43:71 e9.
[15] Beck AT, Steer RA. Manual for the Beck Depression Inventory. San Antonio,
TX: Psychological Corporation; 1993.[16] Teri L. The use of the Beck Depression Inventory with adolescents.
J Abnorm Child Psychol 1982;10:277 e84.
[17] Roberts RE, Lewinsohn PM, Seeley JR. Screening for adolescent depression:
A comparison of depression scales. J Am Acad Child Adolesc Psychiatry
1991;30:58 e66.
[18] Reynolds WM. SIQProfessional Manual. Odessa, FL: Psychological Assess-
ment Resources, Inc; 1988.
[19] Reynolds WM, Mazza J. Assessment of suicidal ideation in inner-city chil-
dren and young adolescents: Reliability and validity of the Suicidal IdeationQuestionnaire-JR. School Psych Rev 1999;28:17 e29.
[20] Shaffer D, Fisher P, Lucas CP, et al. NIMH Diagnostic Interview Schedule for
Children Version IV (NIMH DISC-IV): Description, differences fromprevious versions, and reliability of some common diagnoses. J Am Acad
Child Adolesc Psychiatry 2000;39:28 e38.
[21] Tarter RE, Hegedus AM. The Drug Use Screening Inventory: Its applications
in the evaluation and treatment of alcohol and other drug abuse. Alcohol
Health Res World 1991;15:65 e75.
[22] Tarter RE, Laird SB, Bukstein O, et al. Validation of the Adolescent Drug Use
Screening Inventory: Preliminary findings. Psychol Addict Behav 1992;6:
233e6.
[23] Kirisci
L, Mezzich A, Tarter R. Norms and sensitivity of the adolescent
version of the drug use screening inventory. Addict Behav 1995;20:
149e57.
[24] Tarter RE, Mezzich A, Kirisci L, et al. Reliability of Drug Use Screening
Inventory among adolescent alcoholics. J Child Adolesc Subst Abuse 1994;3:25e36.
[25] Shaffer D, Gould MS, Fisher P, et al. Psychiatric diagnosis in child and
adolescent suicide. Arch Gen Psychiatry 1996;53:339 e48.
[26] Bird HR, Shaffer D, Fisher P, et al. The Columbia Impairment Scale (CIS):
Pilot findings on a measure of global impairment for children and
adolescents. Int J Methods Psychiatr Res 1993;3:167 e76.
[27] Shaffer D, Craft L. Methods of adolescent suicide prevention. J Clin
Psychiatry 1999;60(Suppl 2):70 e4.
[28] Gould MS, Marrocco FA, Hoagwood K, et al. Service use by at-risk youth
after school-based suicide screening. J Am Acad Child Adolesc Psychiatry2009;48:1193 e201.
[29] Gould MS, Greenberg T, Velting DM, et al. Youth suicide risk and preven-
tive interventions: A review of the past 10 years. J Am Acad Child Adolesc
Psychiatry 2003;42:386 e405.
[30] Kim YS, Koh YJ, Leventhal B. School bullying and suicidal risk in Korean
middle school students. Pediatrics 2006;115:357 e63.
[31] Skapinakis P, Bellos S, Gkatsal T, et al. The association between bullying
and early stages of suicidal ideation in late adolescents in Greece. BMCPsychiatry 2011;11:22.
[32] Apter A, Gothelf D, Orbach I, et al. Correlation of suicidal and violent
behavior in different diagnostic categories in hospitalized adolescent
patients. J Am Acad Child Adolesc Psychiatry 1995;34:912 e8.
[33] Apter A, Kotler M, Sevy S, et al. Correlates of risk of suicide in violent and
nonviolent psychiatric patients. Am J Psychiatry 1991;148:883 e7.
[34] Reinecke MA, Schultz TM. Comparison of self ereport and clinician ratings
of depression among outpatient adolescents. Depression 1995;3:139 e45.
[35] Velting DM, Rathus JH, Asnis GM. Asking adolescents to explain discrep-
ancies in self-reported suicidality. Suicide Life Threat Behav 1998;28:
187e96.
[36] Kaplan ML, Asnis GM, Sanderson WC, et al. Suicide assessment: Clinical
interview vs. self-report. J Clin Psychol 1994;50:294 e8.
[37] Olweus D. Sweden. In: Smith PK, et al, editors. The nature of school
bullying: A cross-national perspective. London: Routledge; 1999:7 e27.
[38] Seals D, Young J. Bullying and victimization: Prevalence and relationship to
gender, grade level, ethnicity, self-esteem, and depression. Adolescence2003;38:735 e47.
[39] Veenstra R, Lindenberg S, Oldehinkel AJ, et al. Bullying and victimization in
elementary schools: A comparison of bullies, victims, bully/victims, and
uninvolved preadolescents. Dev Psychol 2005;41:672 e82.
[40] Wolke D, Woods S, Stanford K, et al. Bullying and victimization of primary
school children in England and Germany: Prevalence and school factors.Br J Psychol 2001;92:673 e96.A.B. Klomek et al. / Journal of Adolescent Health 53 (2013) S37 eS42 S42