Acta Psychiatr Scand 2016: 1–17 © 2016 John Wiley & Sons A/S.
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
All rights reserved
DOI: 10.1111/acps.12679
Meta-analysis
Exposure to violence, a risk for suicide in
youths and young adults. A meta-analysis of
longitudinal studies
Castellv
ı P, Miranda-Mendiz

abal A, Par
es-Badell O, Almenara J,
Alonso I, Blasco MJ, Cebri
a A, Gabilondo A, Gili M, Lagares C,
Piqueras JA, Roca M, Rodr
ıguez-Mar
ın J, Rodr
ıguez-Jimenez T,
Soto-Sanz V, Alonso J. Exposure to violence, a risk for suicide in
youths and young adults. A meta-analysis of longitudinal studies.
Objective: To assess the association and magnitude of the effect of early
exposure to different types of interpersonal violence (IPV) with suicide
attempt and suicide death in youths and young adults.
Method: We searched six databases until June 2015. Inclusion criteria
were as follows: (1) assessment of any type of IPV as risk factor of
suicide attempt or suicide: (i) child maltreatment [childhood physical,
sexual, emotional abuse, neglect], (ii) bullying, (iii) dating violence, and
(iv) community violence; (2) population-based case–control or cohort
studies; and (3) subjects aged 12–26 years. Random models were used
for meta-analyses (Reg: CRD42013005775).
Results: From 23 682 articles, 29 articles with 143 730 subjects for
meta-analyses were included. For victims of any IPV, OR of subsequent
suicide attempt was 1.99 (95% CI: 1.73–2.28); for child maltreatment,
2.25 (95% CI: 1.85–2.73); for bullying, 2.39 (95% CI: 1.89–3.01); for
dating violence, 1.65 (95% CI: 1.40–1.94); and for community violence,
1.48 (95% CI: 1.16–1.87). Young victims of IPV had an OR of suicide
death of 10.57 (95% CI: 4.46–25.07).
Conclusion: Early exposure to IPV confers a risk of suicide attempts
and particularly suicide death in youths and young adults. Future
research should address the effectiveness of preventing and detecting
early any type of IPV exposure in early ages.
ACTA PSYCHIATRICA SCANDINAVICA
P. Castellv
ı1,2, A. Miranda-
Mendiz
abal1,3, O. Par
es-Badell1,
J. Almenara4, I. Alonso5,
M. J. Blasco1,2,3, A. Cebria6,
7,8
A. Gabilondo , M. Gili , 9,10
C. Lagares11, J. A. Piqueras12,
M. Roca9,10, J. Rodr
ıguez-
Mar
ın12, T. Rodr
ıguez-Jimenez12,
V. Soto-Sanz12, J. Alonso1,2,3
1
Health Services Research Group, IMIM-Institut Hospital
del Mar d0 Investigacions Mediques, Barcelona, Spain,
2
CIBER Epidemiología y Salud P
ublica (CIBERESP),
Barcelona, Spain, 3Department of Health & Experimental
Sciences, Pompeu Fabra University (UPF), Barcelona,
Spain, 4Area of Preventive Medicine and Public Health,
University of Cadiz, Cadiz, Spain, 5Morales Meseguer
Hospital, Murcia, Spain, 6Department of Mental Health,
Corporaci
o Sanitaria Parc Taulí, Sabadell, Spain,
7
Outpatient Mental Health Care Network, Osakidetza-
Basque Health Service, Donostia-San Sebasti
an, Spain,
8
Mental Health and Psychiatric Care Research Unit,
BioDonostia Health Research Institute, Donostia-San
Sebasti
an, Spain, 9Institut Universitari d’Investigaci
o en
Ciencies de la Salut (IUNICS-IDISPA), University of
Balearic Islands, Palma de Mallorca, Spain, 10Network of
Preventive Activities and Health Promotion, University of
Balearic Islands, Palma de Mallorca, Spain, 11Department
of Statistics and Operative Research, University of C
adiz,
C
adiz, Spain and 12Department of Health Psychology,
Miguel Hernandez University of Elche, Elche, Spain
Key words: child and adolescent psychiatry; suicide;
meta-analysis; trauma
Jordi Alonso, IMIM-Institut Hospital del Mar
d0 Investigacions Mediques, PRBB Building, Doctor
Aiguader 88, 08003 Barcelona, Spain.
E-mail: jalonso@imim.es
Accepted for publication November 14, 2016
1
Castellv
ı et al.

Summations
• For the first time, this systematic review provides an estimate of the risk of interpersonal violence
exposure and suicide.
• All forms of interpersonal violence exposure at early ages are strongly associated with future suicide
attempts and particularly with suicide in youths and young adults.
• Child sexual abuse and bullying are the major contributors of suicide attempts in youths and young
adults.

Considerations
• Heterogeneity was severe for all types of child maltreatment and community violence and suicide
attempts.
• Trim and Fill imputation method suggests the existence of publication bias for childhood physical
and sexual abuse and suicide attempts, which may have led to results overestimating the effect of the
association.

Introduction
More than a million people die, and many more
suffer serious injuries as a result of the preventable
problem of interpersonal violence (IPV) each year
(1). Children and youths are the groups with great-
est risk of being victims of IPV (2). IPV refers to
the violence inflicted on one individual by another,
or by a small group of individuals (1), which
encompasses several types of violence in early life
commonly recognized: (i) child maltreatment
[childhood physical abuse (CPA); childhood sexual
abuse (CSA); childhood emotional abuse (CEA);
neglect]; (ii) bullying; (iii) dating violence; and (iv)
community violence (see Table S1 for typology
and definition of each type of IPV exposure among
youths and young adults) (1, 3–6).
Unfortunately, IPV in early life is relatively
common. Prevalence rates for child maltreatment
range from 5% to 13% (7, 8), for bullying from
5% to 30% (9) and for dating violence from 9% to
12% (10). Early IPV exposure is associated with
multiple emotional and behavioural problems.
Childhood and adolescence are critical develop-
mental periods associated with increased sensitivity
to long-term remodelling behaviour (11). One con-
sequence might be a higher vulnerability to suicidal
behaviours and even to death by suicide (12).
Suicide constitutes a serious public health con-
cern. Over the past 45 years, worldwide suicide
rates have increased by 60%, youths being the
group at highest risk in a third of the countries,
both developing and developed countries, being
suicide the second cause of death in this group
(13). To date, three systematic reviews, with no
meta-analysis, have reported an association for
child maltreatment (14, 15) and dating violence
(16) with suicide-related behaviours. Additionally,
some meta-analyses have been previously con-
ducted estimating the risk of child maltreatment
and suicide attempts, but only in adult popula-
tions. Results showed that victims of child
maltreatment had an increased risk of adult sui-
cide attempts ranging from 1.85 to 3.0 (17, 18).
However, the pooled risk of CSA was estimated
including only longitudinal studies. Recently, van
Geel et al. (19) and Holt et al. (20) showed that
for bullying, the risk estimates for suicide
attempts including only cross-sectional studies
were 2.55 and 2.94 respectively. To date, we have
not found any published meta-analyses for other
forms of IPV mentioned above as risk factor of
suicidal behaviours.
Despite these previously published reviews, no
estimation has yet been performed for suicide, the
most fatal behaviour. Furthermore, there is no esti-
mate of pooled risk for adolescent and young vic-
tims of IPV, a population especially vulnerable to
presenting suicidal behaviours at early ages, based
only on longitudinal studies. Finally, in terms of
public health burden of suicide and implications
for policy and prevention, it is important to con-
sider relative risk together with the prevalence of
exposures associated with suicidal behaviours in
populations using attributable risk methods (21).
However, no estimations have been made calculat-
ing the proportion of suicidal behaviours which
may be reduced by any IPV exposure using popu-
lation attributable risks (PARs) among youths and
young adults. Only one published study estimated
that CSA exposure contributes to total suicide
attempts in 10% of men, and 21% of women in the

2

adult population, pointing out that CSA exposure
may be a major contributor (17). From a public
health perspective, it is important to assess what
proportion of suicide attempts and suicide deaths
may be avoided for each form of IPV exposure.
To the best of our knowledge, no systematic
reviews have been published assessing the most
common forms of exposure to IPV as risk factors
of suicidal behaviours in youths and young adults.
This systematic review tries to fill this knowledge
gap, in particular the level of association between
early IPV exposure and suicide-related behaviour
consequences in youths and young adults.
Aims of the study
We assessed (i) the risk of suicide attempts and of
suicide deaths in youths and young adults for pre-
vious exposure to a comprehensive series of inter-
personal violence types; and (ii) the population
attributable risks of suicide attempt and suicide
associated with interpersonal violence.
Based on previous published meta-analyses, we
hypothesized that youths and young adults
exposed early to any type of interpersonal violence
would have higher rates of suicide attempts and
suicide than their non-exposed counterparts. We
also hypothesized that the risks would be similar
across all types of interpersonal violence.
Method
This article is based on a broad systematic review
to identify a comprehensive list of risk factors of
suicidal behaviours in ages from 12 to 26 years.
The original research protocol was previously reg-
istered at PROSPERO (Reg: CRD42013005775)
(22). Recommendations from the MOOSE guideli-
nes for systematic reviews (23) in relation to han-
dling and reporting of results were considered. The
search strategy was devised for Medline by two
investigators with previous experience of perform-
ing systematic reviews of observational studies
(PC; OPB) and adapted for the other databases.
More information about the search strategy and
selection criteria of the broad systematic review is
provided in Appendix S1, and MOOSE checklist
in Table S2 (see Appendix S1 and Table S2).
Inclusion criteria
For this article, we added the following specific
selection criteria: population-based case–control or
cohort studies which assessed any form of IPV: (i)
child maltreatment (CPA, CSA, CEA, or neglect);
(ii) bullying; (iii) dating violence; or (iv)
Interpersonal violence and youth suicidal behaviour
community violence as a risk factor of suicide
attempts or suicide, compared to their non-
exposed peers of the same age range (12–26y) (see
Table S1 for typology and definition of each type
of IPV exposure among youths and young adults).
Suicide attempt was defined as any act of self-
injury with intention to die, and suicide was
defined as any fatal act done with the intention to
take one’s own life (24).
From eligible studies, we abstracted the follow-
ing: sample size; age range; mean age; number of
females; country; study design; suicide outcome;
type of sample recruited; type of IPV assessed; and
percentage of people exposed to IPV; and adjusted
analyses. From cohort studies, additional data
were extracted relating to the follow-up: length;
attrition rates; percentage of suicide attempts; and
percentage of suicides. Information obtained about
risk factors consisted of odds ratio (OR) and 95%
confidence intervals (95% CIs), or beta coefficients
(b) and standard error (SE). Multivariate analyses
prevailed over bivariate analyses.
Quality assessment
The Newcastle–Ottawa Scale (NOS) was used for
assessing the quality of studies (25). The NOS uses
a ‘star system’ in which a study is evaluated on
three broad perspectives: the selection of the study
groups; the comparability of the groups; and the
ascertainment of either the exposure or outcome of
interest for case–control or cohort studies respec-
tively. The scale consists of eight questions with
different responses; the response which indicates
the highest quality gets a star, except for compara-
bility item which can get two stars. The highest
possible score is nine stars.
Data synthesis
A bottom-up strategy was used to implement each
of the meta-analyses. First, we assessed each form
of child maltreatment separately (CPA, CSA, CEA
and neglect). We performed sensitivity analyses in
cases where heterogeneity was severe. If any of the
included samples was a source of heterogeneity, we
excluded it. The samples finally selected were then
included in the meta-analysis for child maltreat-
ment in general, and this was subsequently incor-
porated into the meta-analysis of any type of IPV.
Similar procedures were applied to bullying, dating
violence and community violence. In case of multi-
ple publications of the same sample and predictive
factors, results from the largest sample and longest
follow-up were selected.
3
Castellv
ı et al.
Population attributable risk (PAR) was also cal-
culated from cohort studies using the formula:
PðRR  1Þ
PAR ¼
1 þ PðRR  1Þ
where P is the prevalence of being exposed to any
form of IPV obtained through available data from
some of the cohort studies included in the meta-
analysis and RR is the relative risk of suicide
attempt in exposed vs. non-exposed individuals
based on data from the studies included.
The OR was then converted to RR using the
formula:
OR
RR ¼
ð1  P0 Þ þ P0 OR
where P0 is the incidence of suicide attempts dur-
ing the follow-up in non-exposed individuals (26),
calculated through meta-analysis using data avail-
able from cohort studies.
The proportion of heterogeneity was calculated
using the Higgins test (I2) and its significance deter-
mined using a chi-square test. P-values < 0.10 were
considered as statistically significant. Heterogene-
ity was defined as low (<30%), moderate (30–50%)
and severe (>50%) (27). We performed sensitivity
analyses when severe heterogeneity existed for
studies included in the meta-analyses. The follow-
ing variables were considered as moderator factors
and, as a consequence, as possible sources of
heterogeneity. We excluded studies: (i) with low
study quality; (ii) with case–control design; (iii)
with analyses performed without controlling for
any confounders, and then both without control-
ling for any confounders and adjusted by only one
confounder; (iv) with attrition rate >30% during
the follow-up; (v) with length of follow-up
<6 years; and (vi) which assessed suicidal beha-
viour with a non-validated instrument. We used
random-effect meta-analyses to produce pooled
estimates because we assumed that the identified
studies differed among themselves in several
aspects such as different population, countries, age
range, study design, instrument used or analyses
conducted. Publication bias was determined using
funnel plots and Egger’s regression asymmetry
test. In the presence of significant asymmetry, we
used Duval and Tweedie’s Trim and Fill test (28)
to reduce publication bias effect by imputing new
potential unpublished studies, and obtaining a new
pooled estimate.
STATA software version 13 with the Metan pack-
age was used to conduct meta-analyses, including
heterogeneity and publication bias statistical
4
analyses, and with the Metaprop package for
weighted proportion of PAR calculations.
Results
Included studies
We identified 1575 full-text articles for eligibility,
of which 1541 were excluded. All reasons for exclu-
sion are detailed in Fig. 1.
A total of 34 articles assessed some type of IPV
and were included in qualitative synthesis: child
maltreatment = 24; bullying = 4; dating vio-
lence = 4; and community violence = 7. These arti-
cles represent data from 26 different studies
covering 143 730 subjects. They were based on
general population or school samples, except for
one from primary care (29) and one from a specific
sample of lesbian, gay or bisexual (LGB) youths
(30). Over 50% of the samples were from the Uni-
ted States. Twenty-two (84.6%) studies assessed
suicide attempt, mostly using cohort design
(72.7%). Only three case–control studies assessed
suicide. One study assessed both outcomes without
stratification, and it was included only in the analy-
ses of studies assessing suicide attempts. In cohort
studies, incidence rates of suicide attempt ranged
from 1.2% to 32% with a length of follow-up from
1 to 25 years. Attrition rates during follow-up ran-
ged from 0.8% to 51.7% (Table 1).
Quality of studies reviewed
The majority of studies were awarded with 6 or
more stars. However, five (20.8%) cohort studies
(12, 31–34) and one (10%) case–control study (29)
had an overall lower quality (<6 stars): A struc-
tured interview was not used for the ascertainment
of the exposure in two cohort studies, and the con-
trol group was not sufficiently well described in
one case–control study (29). Only one case–control
study did not consider any potential confounding
variables (35). Finally, six cohort studies had
lengths of follow-up <6 years and nine cohort
studies had attrition rates higher than 30% (see
Table S3).
Risk of suicide attempts
Child maltreatment and subtypes. We identified 22
articles which assessed child maltreatment expo-
sure as a risk factor of suicide attempts, among
which 52.4% of them reported CPA, 57.1% CSA,
4.8% CEA and 33.3% neglect. Over 65% of sam-
ples reported a significant association between
some aspect of child maltreatment and suicide

Fig. 1. Modified version of PRISMA diagram of included studies. [Colour figure can be viewed at wileyonlinelibrary.com]
attempts (75% CPA; 90.9% CSA; not reported
CEA; 25% neglect).
Childhood physical abuse (CPA). The overall
pooled estimate with 12 samples showed a signifi-
cantly higher risk for those exposed to CPA
(OR = 2.53, 95% CI: 1.66–3.87). Severe hetero-
geneity was observed (I2 = 86.5%) (see Fig. S1),
which was not reduced after sensitivity analyses.
Additionally, sensitivity analysis excluding non-
adjusted estimates and then excluding both non-
adjusted and those adjusted only by one variable
Interpersonal violence and youth suicidal behaviour
showed that the more fully adjusted analyses
yielded lower risks (excluding those estimates with
non-adjusted ORs = 2.17; excluding those esti-
mates with non-adjusted ORs or adjusted by one
variable only = 1.94), but heterogeneity was not
reduced. The funnel plot seemed to be asymmetric
and significant suggesting publication bias
(P < 0.001). The Trim and Fill analysis indicated
that seven samples were potentially missing. The
imputation and inclusion of these samples showed
a lower and non-significant effect size [OR = 1.39
(95% CI: 0.80–1.77)], indicating that probably
5
6
Table 1. Study characteristics of included articles

Age range (at Mean age (at Mean annual Instrument

follow-up in follow-up Total sample Sample at % of suicide incidence Type used to assess
Study cohort in cohort Length of at baseline the end behaviours at rate during of IPV Rates of suicidal
Castellv
ı et al.

Author (Study) Country design Population studies) (y) studies) (SD) follow-up (% women) (% attrition) follow-up follow-up (%) assessed any IPV (%) Adjusted for behaviour

Studies assessing suicide attempts

De Wilde et al. The Case– Students 14–21 NI a 48 vs. 43 (79.1) a a a CM (CPA; CSA) CPA = 15.4; – Medical records
(1992) (35) Netherlands control CSA = 19.8
Garnefski et al. The Case– Students 13–20 16.0 a 285 vs. a a a CM (CPA; CSA) CPA = 36.3; – One item
(1992) (59) Netherlands control 285 (64.9) CSA = 16.8
Beautrais et al. New Case– General 13–24 19.4 (3.0) a 129 vs. 153 a a a CM (CPA; NI CPA = None; Hospital
(1996) (60) Zealand control vs. 21.4 (1.6) CSA; Neglect) CSA & admission
Neglect =
Other
childhood
experiences
Silverman et al. United Cohort General 15–21 NI 17 y 777 (49.9) 375 (51.7) 2.7 0.16 CM (Any; CPA; Any = 10.7; – One item
(1996) (61) States CSA; Neglect) CPA = 5.9;
CSA = 6.7
Kaplan et al. United Case– General 12–18 15.0 (6.0) a 99 vs. 99 a a a Any – Suicide
(1997) (62) States control maltreatment Probability Scale
Brown et al. United Cohort General 16–26 NI 17 y 776 639 (19.7) 6.2 0.36 Maltreatment CM = 12.7; Age; Gender; DISC-III
(1999) (63) States (Any; CPA; CPA = 6.9; Other risk
CSA; Neglect) CSA = 3.4; factors
Neglect = 6.1
Lyon et al. United Case– Primary 12–17 14.8 a 38 vs. 76 (18.4) a a a CM (Any; CM = 24.6; – Medical records
(2000) (29) States control care Neglect) Neglect = 11.4
Wichstrom Norway Cohort Students 14–22 NI 2y 11 918 (41.1) 9679 (28.8) 8.2 4.1 CM (Neglect) NI History of Two items
(2000) (31) suicidal
behaviours
Plunkett et al. Canada Cohort Students 13–24 15 vs. 19 9y 187 abused vs. 183 (32.5) 32.4 3.6 CM (CSA) NA – A non-validated
(2001) (32) 84 non-abused structured
interview
Fergusson et al. New Cohort General 21–25 NI 25 y 1265 966 (23.5) 9.4 0.38 CM (CPA; CSA = 11.4; Changes of Two items
(2003, 2008) Zealand CSA) CPA = 9 parents;
(64, 65) Childhood
(Christchurch physical
Health and abuse; Family
Development standards
Study) of living;
Gender; IQ;
Parental
attachment;
Parental history
of drug use
D’Augelli et al. United Cohort General 17–21 NI 2y 521 368 (29.4) 17.0 8.5 CM (CEA) Mean (SD) = – Two items
(2005) (33) States 1.20 (0.74)
Ackard et al. United Cohort General NI 20.4 (0.8) 5y 1710 (54.2) 1516 (11.4) 1.2 0.24 DV DV = 8.2 History of Two items
(2007) (66) States suicide
(Project EAT) attempts
 Table 1. (Continued)

Age range (at Mean age (at Mean annual Instrument

follow-up in follow-up Total sample Sample at % of suicide incidence Type used to assess
Study cohort in cohort Length of at baseline the end behaviours at rate during of IPV Rates of suicidal
Author (Study) Country design Population studies) (y) studies) (SD) follow-up (% women) (% attrition) follow-up follow-up (%) assessed any IPV (%) Adjusted for behaviour

Brezo et al. Canada Cohort Students 19–24 21.4 22 y 3017 (47.2) 1776 (41.1) Any = 9.3; Any = 0.42; CM (Any; CM = 40; Disruptive . Suicidal Intent
(2007, 2008), Repeated = 1.8 Repeated = 0.08 CPA; CSA) CPA = 20.6; behaviours; Family Scale
Wanner et al. CSA = 9.9 history suicidal
(2012) (67-69) behaviours; Gender
(Quebec Study
in Canada)
Salzinger et al. United Cohort Students 15–18 16.5 (0.5) 6y 100 abused 153 (23.5) 12.4 2.07 CM (CPA) NA Gender; Previous Youth Risk
(2007) (34) States vs. 100 life events Behavior Survey
non-abused
Larsson and Norway Cohort Students 13–16 14.7 (0.5) 2y 2397 (49.4) 2370 (0.8) 3.0 1.5 Bullying Bullying = 9.4 Depressive Two items
Sund (2008) symptoms;
(70) (South Friend attempted
& North suicide; Functional
Trondelag impairment;
Norway Study) Gender; Tobacco
use by gender
Haynie et al. United Cohort Students 12–16 NI 1y 14 738 11 949 (18.9) 3.5 3.5 CM (Any; CM = 30; Age; Depression; Two items
(2009) (71) States CPA); DV; CV CSA = 8; Ethnicity; Gender;
DV = 8; Parent–child
CV = 34 closure; Parent–child
relationship; Race;
School grades;
Sexual activity;
Social class;
Violent behaviour
Wilcox United Cohort Students 20–23 13.8 (0.3) 15 y 2311 (50.2) 1570 (38.1) NI NI Community CV = 81.1 Alcohol abuse One item
et al. (2009) States violence or dependence;
(12) (Good Drug abuse
Behavior or dependence;
Game) Major depressive
episode; Post-
traumatic stress
disorder

7
Interpersonal violence and youth suicidal behaviour
8
Table 1. (Continued)

Age range (at Mean age (at Mean annual Instrument

follow-up in follow-up Total sample Sample at % of suicide incidence Type used to assess
Study cohort in cohort Length of at baseline the end behaviours at rate during of IPV Rates of suicidal
Castellv
ı et al.

Author (Study) Country design Population studies) (y) studies) (SD) follow-up (% women) (% attrition) follow-up follow-up (%) assessed any IPV (%) Adjusted for behaviour

Thompson MP, United Cohort Students 15–26 21.4 (0.1) 14 y 20745 13 110 (36.8) 3.6 0.26 CM (CPA; CM = NI; (i) Maltreatment = One item
Light (2011), States CSA; DV = 22.2; Gender; Somatic
Fried et al. Neglect); CV = 24.4 symptoms.
(2012), Exner- DV; CV (Males), (ii) Dating =
Cortens 10.9 (Females) Age; Child
et al. (2013), maltreatment;
Soller (2014), Gender; Pubertal
Turanovic and status; Race;
Pratt (2015) Socioeconomic
(36, 37, 72–74) status.
(Add Health) (iii) Community =
Depression;
Failing grade;
History of tobacco
consumption;
Number of risk
factors; Problem
solving;
Psychotherapy;
Race/Ethnicity
Young et al. United Cohort Students 15 NI 8y 2586 (50.4) 1860 (28.1) 6.1 0.76 CM (Neglect); NI Academic Two items
(2011) (75) Kingdom Bullying performance;
(West of Age of parents;
Scotland Depression;
11–16 Study) Deprivation; Family
characteristics;
Gender;
Neighbourhood
perception; Parental
control; Religion;
School connectedness;
Social class;
Use of psychiatric
services
Christiansen Denmark Nested General 16–22 Males = 22 y 3465 vs. NI 4.8 0.22 CV CV = 3.0 Cohabitation; Danish Population
et al. (2012) case– 17.8 (2.4); 69300 (78.7) (Males = 6.7; Death; Education Register
(76) control Females = Females = 2.0) level; Income;
16.8 (2.3) Parents’
psychiatric history;
Psychiatric
history; Use
pharmacological
drugs
 Table 1. (Continued)

Age range (at Mean age (at Mean annual Instrument

follow-up in follow-up Total sample Sample at % of suicide incidence Type used to assess
Study cohort in cohort Length of at baseline the end behaviours at rate during of IPV Rates of suicidal
Author (Study) Country design Population studies) (y) studies) (SD) follow-up (% women) (% attrition) follow-up follow-up (%) assessed any IPV (%) Adjusted for behaviour

Mustanski United Cohort LGB 16–20 18.7 (1.3) 4y 237 (47.7) 216 (8.4) 5.5 1.38 CV NI Age; Gender; Two items
and Liu States Race; Sexual
(2013) (30) orientation
Mars et al. United Cohort General 16–17 NI 16 y 14062 4799 (34.1) 0.7 0.04 CM (CSA; CPA = 3.0; Gender CASE
(2014) Kingdom CPA); CSA = 0.5;
(77) (ALSPAC) Bullying Bullying = 19.8
Studies assessing completed suicide
Shafii et al. United Case– General 12–19 NI a 20 vs. a a a CM (Any) 43.2 – Forensic register
(1985) (38) States control 17 (10.8)
Davidson et al. United Case– Students 14–19 NI a 14 vs. 39 (10.8) a a a CV NA – Forensic register
(1989) (40) States control
Brent et al. United Case– General 13–19 NI a 67 vs. 67 (14.9) a a a CM (Any) Lifetime Age Forensic register
(1993, 1999) States control CM = 18.1
(39, 78) Current CM = 4.1
Studies assessing both completed suicide and suicide attempts
Klomek et al. Finland Cohort General 25 25 y 6017 (54.1) 5302 (11.9) NI NI Bullying Males = 57.2; Conduct Suicide
(2009) (52) Females = 39.8 problems; attempts =
(Epidemiological Depression Hospital
Multicenter Child admission;
Psychiatric Suicide death =
Study in Finnish
Finland) Population
Register

ALSPAC, Avon Longitudinal Study of Parents and Children; CASE, Child and Adolescent Self-harm in Europe; CEA, childhood emotional abuse; CM, childhood maltreatment; CPA, childhood physical abuse; CSA, childhood sexual abuse; CV, commu-
nity violence; DISC-III, Diagnostic Interview Schedule for Children for DSM-III; DISC, Diagnostic Interview Schedule for Children for DSM-IV; DV, dating violence; IPV, interpersonal violence; LGB, lesbian, gay or bisexual; NI, no information; SD, stan-
dard deviation; y, years.
a
Not applicable.

9
Interpersonal violence and youth suicidal behaviour
Castellv
ı et al.
unpublished studies exist which were not included,
and therefore, the impact attributable to publica-
tion bias is potentially important.
Childhood sexual abuse (CSA). The results of the
meta-analysis for CSA including 10 samples indi-
cated the largest average effect size for child mal-
treatment (OR = 3.87, 95% CI: 2.31–6.49), but
results showed severe heterogeneity (I2 = 76.2%)
(see Fig. S2). The pooled risk was reduced when
non-adjusted estimates were excluded, showing a
similar risk when we excluded unadjusted estimates
or those adjusted by only one variable (excluding
those estimates with non-adjusted ORs = 3.26;
excluding those estimates with non-adjusted ORs
or adjusted by one variable = 3.25), but no reduc-
tion of heterogeneity was observed. Other sensitiv-
ity analyses performed resulted in no reduction of
heterogeneity. The publication bias funnel plot
appeared to be asymmetric, suggesting publication
bias (P = 0.005). The Trim and Fill method added
five potentially missing samples, and the imputed
new effect size was lower but still significant
(OR = 1.94, 95% CI: 1.14–3.31).
Childhood emotional abuse (CEA). Only one study
assessed CEA exposure as a risk factor of suicide
attempt (33), showing that children exposed to
CEA had a higher mean number of suicide
attempts than non-exposed children, but they did
not report whether the difference was significant.
Neglect. The pooled OR of suicide attempt based
on four samples was non-significant (OR = 1.76,
95% CI 0.71–4.36). Severe heterogeneity was
observed (I2 = 75.2%), but no publication bias
(P = 0.101) (see Fig. S3). Sensitivity analysis was
only performed for study design, and heterogeneity
was still severe (I2 = 75.4%).
After sensitivity analyses for CPA, CSA and
neglect, no reasons for excluding samples were
found. The pooled OR of suicide attempt among
maltreated children including 32 samples was 2.25
(95% CI: 1.85–2.73) with severe heterogeneity
(I2 = 88%) (Fig. 2).
Bullying. Five samples were included in the meta-
analysis. We found that victims of bullying have a
significantly higher risk of suicide attempt
[OR = 2.39 (95% CI: 1.89–3.01)]. No heterogene-
ity was observed (I2 = 2.3%) (Fig. 2). Although
the funnel plot suggested asymmetry, it was not
statistically significant (P = 0.474).
Dating violence. Seven samples were included in
the meta-analyses. Results showed an increased
10
risk of suicide attempts for victims of dating vio-
lence compared to their non-exposed counterparts
[OR = 1.65 (95% CI: 1.40–1.94)] (Fig. 2). Neither
heterogeneity (I2 = 0%) nor publication bias
(P = 0.553) was found.
Community violence. Eight samples from five
articles assessed various forms of community
violence. One sample assessed LGB victimiza-
tion exposure (30). From the Add Health study,
three articles assessed being threatened with gun
or knife, being cut or stabbed, being assaulted
and being raped as risk factors (36, 37).
Finally, three articles assessed community vio-
lence without distinguishing its form. A signifi-
cant association between community violence
and suicide attempt was reported in 66.7%
studies, and the pooled OR was 1.48 (95% CI:
1.16–1.87) (Fig. 2). Severe heterogeneity was
observed (I2 = 76.5%), but no publication bias
(P = 0.401). Sensitivity analyses showed a
reduction of heterogeneity only when studies
with attrition rates >30% were excluded
(I2 = 0%), with a similar risk estimate
(OR = 1.78).
Interpersonal violence (IPV). Fifty-one samples
from 24 articles involving IPV exposure were
included in qualitative analyses. The overall
pooled estimate for the association between expo-
sure to IPV and suicide attempts was 1.99 (95%
CI: 1.73–2.28). Severe heterogeneity was found
(I2 = 84.9%) (Fig. 2), most likely because several
types of IPV were included.
Risk of suicide deaths
Only six samples from three articles (38–40)
were identified assessing the association between
any form of IPV and suicide. Five samples mea-
sured any child maltreatment (38, 39) and one
sample community violence (40). Brent et al.
(1999) (39) measured any child maltreatment
stratified by gender and by current and lifetime
abuse resulting in four independent samples. All
were case–control studies with subjects aged 12–
19 years, and only one study reported adjusted
ORs. Only two estimates from identified studies
were significantly associated with suicide: life-
time childhood abuse in males (OR = 49.3) (39);
and community violence (OR = 23.3) (40). Evi-
dence from meta-analyses indicated a significant
10-fold risk between any IPV exposure and sui-
cide [OR = 10.57 (95% CI: 4.46–25.07)]. Low
heterogeneity was found (I2 = 4%; P = 0.394)
(Fig. 3).
 Interpersonal violence and youth suicidal behaviour

Fig. 2. Forest plot of each type of interpersonal violence as risk factor of suicide attempt. [Colour figure can be viewed at wileyonli-
nelibrary.com]

Population attributable risk (PAR) followed by CPA (8.6%), child maltreatment

(7.1%), community violence (6.8%), dating vio-
We estimated PARs on the basis of the range of
lence (4.9%) and neglect (3.5%). Overall, the elimi-
values of the prevalence of being exposed to each
nation of any early exposure to IPV would
form of IPV. The highest percentage of suicide
theoretically reduce suicide attempts by 9%. Data
attempts in adolescents and young adults were
were not available for CEA and suicide attempts,
attributable to bullying (22.2%) and CSA (14.3%),

11
Castellv
ı et al.

Fig. 3. Forest plot of each type of interpersonal violence as risk factor of suicide. [Colour figure can be viewed at wileyonlinelibrary.
com]

Table 2. Population attributable risk (PAR) calculations for each type of interper-
sonal violence (IPV) exposure as risk factor of suicide attempt interpersonal violence (IPV), regardless of the
type, are consistently more likely than non-exposed
Prevalence of
Type of IPV exposure IPV % (95% CI) P0 (%) RR PAR % (95% CI)
peers to present suicide attempts in the short term
with a two-fold risk. In addition, we found some
IPV 9 (5–13) 5 1.90 9.0 (5.1–13.2) evidence of a much higher risk of dying by suicide
Child maltreatment 7 (4–11) 6 2.09 7.1 (4.2–10.7)
before reaching 20 years of age. According to their
CPA 7 (3–12) 5 2.35 8.6 (3.9–13.9)
CSA 7 (2–17) 5 3.38 14.3 (4.6–28.8) population attributable risks (PARs), childhood
CEA – – – – sexual abuse (CSA) and bullying were the IPV
Neglect 5 (4–7) 3 1.72 3.5 (2.8–4.8) exposures contributing the most to suicide attempts
Bullying 22 (7–42) 3 2.29 22.2 (8.3–35.2)
Dating violence 8 (7–10) 1 1.64 4.9 (4.3–6.0)
in youths and young adults.
Community violence 16 (0–54) 3 1.46 6.8 (0–19.9) Our systematic review has several strengths: (i) a
broad-scope search in several databases and differ-
CEA, childhood emotional abuse; CPA, childhood physical abuse; CSA, childhood ent languages was conducted, with peer review in
sexual abuse; IPV, interpersonal violence; P0, prevalence of suicide attempts in
people non-exposed to IPV; PAR, population attributable risk; RR, relative risk.
the screening phase, independent review in data
extraction phase and use of methods for minimiz-
ing bias; (ii) we contacted authors of eligible stud-
nor for any of the IPV exposures and suicide ies for further information; (iii) manual search and
(Table 2). grey literature search were also carried out; and
(iv) meta-analyses were carried out using adjusted
ORs extracted from original articles; (v) except for
Discussion CSA, for which previous literature reported similar
PAR calculations to ours (females 22.3% vs. 21%;
Summary of main findings
males 10.8% vs. 10%) (17), as far as we are aware
Our systematic review including 52 samples from no PAR calculations for other forms of IPV expo-
26 studies provides strong evidence that early vic- sure as a risk factor of suicide attempts have been
tims, from childhood to young adulthood, of any estimated previously.

12

Our study overcame some limitations of previ-
ous systematic reviews (14–20), by measuring the
most prevalent IPV exposures exclusively in chil-
dren and youths, and quantifying the strength of
the association of each form of IPV for suicide
attempts and suicide for these specific populations.
In addition, while previous meta-analyses included
a majority of cross-sectional studies, we only
included cohort and case–control studies allowing
us to make some inferences about causality. How-
ever, information about exposure in case–control
studies is retrospective and therefore subject to
recall bias. Additionally, concurrent mental health
factors at the moment of reporting may influence
our results (41), and any unadjusted estimates
included may have overestimated our obtained
risks. For suicide attempt, most of them (73%)
used a cohort design, and in most studies,
extracted ORs were adjusted (70%). However, for
suicide, all identified studies were case–control.
Therefore, our inferences about causality and tem-
porality are more robust for suicide attempt than
for suicide death. We included only population-
based studies, which could have resulted in a
higher heterogeneity. However, the quantitative
assessment of risk factors from population-based
studies provides more useful information about
the global magnitude of the impact of these trau-
mas, to guide prevention and early-intervention
strategies at the community level. Moreover, after
excluding studies which appeared to be sources of
heterogeneity, OR values were very similar. How-
ever, we cannot conclude that our results are
robust regarding heterogeneity because of two lim-
itations: (i) heterogeneity became statistically non-
significant when only seven or less studies were
included (except for neglect for which only four
samples were included in the analysis); this might
be due to a lack of statistical power; and (ii)
although effect sizes remained similar when sensi-
tivity analyses were performed, heterogeneity
remained. Also, we used the Newcastle–Ottawa
Scale (NOS) to assess the quality of the studies
reviewed. The Cochrane Collaboration recom-
mends this instrument for observational studies,
and it has been widely used in previous systematic
reviews (42–44). However, evidence about its valid-
ity is still limited (25).
Comparison with other studies
Consistently with previous reviews, we found that
early exposure to child maltreatment is associated
with suicide attempts later in life. But, to the best
of our knowledge, no previous meta-analysis had
considered suicide attempts in youths and young
Interpersonal violence and youth suicidal behaviour
adults only. Our results show that, compared to
their non-exposed peers, individuals exposed early
to child maltreatment have a significant two-fold
increased risk of suicide attempts as youths/young
adults, a two-fold increased risk when exposed to
CPA and a four-fold increased risk of CSA. For
neglect, the risk found was not significant. We iden-
tified only one article assessing CEA as a risk factor
of suicide attempt in youths/young adults, although
exposure to CEA is common (45). Thus, further
research is needed assessing exposure to CEA and
neglect as risk factors of suicide behaviours.
No previous meta-analyses have estimated the
risk of suicide attempts among youths/young
adults who had been exposed to dating violence, or
to community violence. Our results showed a risk
for both exposures of 1.50, approximately. For
exposure to bullying, the risk was 2.39, which was
higher than that for dating and community vio-
lence, but somewhat lower than that of a previous
systematic review, which included cross-sectional
studies and reported risks ranging from 2.55 to
2.94. However, the risks may have been overesti-
mated (46). Therefore, our results provide a more
accurate estimation of the risk than previous meta-
analyses.
A two-fold increased risk of suicide attempt in
youths/young adults was found for those previ-
ously exposed to any type of IPV. Overall, this
result was not influenced by any moderator vari-
able, and no publication bias was observed for bul-
lying, dating and community violence. Because
only eight or fewer studies were included, we can-
not rule out that we had insufficient statistical
power to detect publication bias. Furthermore,
while an association probably exists between vic-
tims and suicidal behaviour, the risk for CPA and
CSA might have been overestimated as suggested
by some Trim and Fill imputation method analy-
ses. Furthermore, IPV exposure has long-term
health consequences. Victims of child maltreat-
ment, whether sexual or non-sexual, are more
likely to present mental disorder, drug use, suicide
attempts, sexually transmitted infections and risky
sexual behaviour (18, 47, 48). Similar results have
been found for bullying and dating violence,
whereby victims are more likely to report more
mental health problems and more self-harm beha-
viours in adulthood (49, 50).
Although suicide in early life is a fatal outcome,
with huge emotional, social and physical conse-
quences in family and peers, the aetiology and pre-
vention are poorly understood. Our review fills a
knowledge gap on the risk factors of suicide in
youths and young adults. This is the first meta-
analysis to assess the association between exposure
13
Castellv
ı et al.

to any form of IPV and suicide in youths and Future research

young adults. Early exposure to any IPV is associ-
Here, IPV has been consistently shown to be asso-
ated with a 10-fold increased risk of suicide
ciated with youth suicide behaviours; however,
between 12 and 19 years of age, when compared
future research is needed for a more accurate esti-
with that of their non-exposed peers. According to
mation of the magnitude of risks for suicide, based
the stress–diathesis model of suicidal behaviour
on population-based longitudinal studies. Also,
(51), these results suggest that a subgroup of
the role of specific moderators, such as impulsivity,
exposed children and adolescents are considerably
aggression and disinhibition, should be studied.
more vulnerable to the consequences of early-life
Gene–environment studies are also needed to iden-
trauma, substantially increasing their risk of dying
tify children with high vulnerability to die by sui-
by suicide (52). These results are new and relevant,
cide as a response to early trauma exposure.
but need to be interpreted with caution as they are
Importantly, research to estimate the risk between
based on a small number of case–control studies
IPV and suicidal behaviour should be extended to
reporting mostly unadjusted estimates.
developing countries.
From a public health perspective, comprehen-
Generalization of conclusions sive, multifaceted and effective suicide prevention
programmes and health policies should be devel-
Some additional issues should be taken into con-
oped and implemented to substantially reduce
sideration in relation to the generalization of our
the number of youth suicide behaviours and, as a
results. First, although a wide range of samples
consequence, the burden of disease. Fortunately,
and populations were examined, heterogeneity
suicide deaths are relatively uncommon in most
across studies was found for some IPV exposures:
populations (e.g., the one-year odds of dying by
IPV, community violence and any child maltreat-
suicide in the United States is around 0.00013
ment, including CPA, CSA and neglect. The recall
persons/year (54)). However, suicide has huge
of adversities in early life, especially for child mal-
family and social consequences, and even more
treatment, by the subject may be affected by the
when the victim is an adolescent or youth. If we
age of report (recall bias) and by concurrent men-
estimate suicidal behaviour in terms of disability-
tal health at the moment of report, such as depres-
adjusted life-years (DALYs) among youths from
sion or psychological distress (41), which may
10 to 24 years of age, self-inflicted injuries are
increase the heterogeneity between studies. Hetero-
one of the main causes of DALYs worldwide
geneity found for IPV and community violence
(55), and the second cause of death among this
exposures is probably due to the inclusion of sev-
population (13). Each youth suicide has a poten-
eral types and definitions involved. Second,
tial of 60 years of life lost (YLLs), and suicide
although our review was based on the published
attempts have a high potential impact in term of
literature with secondary searching of additional
years lost because of disability (YLDs). Further-
references of particular study types, publication
more, violence has been identified as the fourth
bias was observed only for CPA and CSA. As the
cause of DALY in youths (55), and the exposure
Trim and Fill imputation method suggested, stud-
is rather prevalent. Our systematic review showed
ies with statistically significant and positive results
a lifetime prevalence of childhood maltreatment
are more likely to be published than studies with
from 10% to 40%, bullying from 9% to 20%
negative or null findings, and we cannot rule out
and dating violence from 8% to 22% (see
that this may cause inflated estimates of pooled
Table 1). Therefore, implementing preventive and
risk of suicidal behaviours for these particular
effective programmes to reduce both exposures
exposures. Third, for two exposures, CPA and
and outcomes, violence and suicide, is mandatory
CSA, sensitivity analyses showed that adjusting for
for the health of youths and young adults. Based
more variables resulted in lower risk estimates, but
on our PAR calculations, and assuming that
still with a statistically significant association.
eliminating the exposure will not affect other risk
However, the Trim and Fill imputation method
factors, effective interventions in youths and
suggests that victims of CPA during childhood
young adults exposed to CSA (56) and bullying
have a non-significant risk of a suicide attempt.
(57) could theoretically reduce suicide attempts
Therefore, further research using appropriate
by around 14.3% and 22.2% respectively.
design and analyses is needed about the true risk
Although the complete elimination of the expo-
for these two exposures, especially for CPA. In
sure is relatively unlikely, children and youths
conclusion, the risks obtained from the initial
with these IPV exposures should be considered as
meta-analysis in these two exposures may have
a potential target for suicide prevention
been overestimated (53).

14

programmes. Primary care and emergency room
teams composed by expert multidisciplinary pro-
fessionals should have a pivotal role in the pre-
vention, identification and management of early
victims of IPV (58). Screening of early IPV expo-
sure and counselling of youth victims and their
parents or caregivers is recommended.
Acknowledgements
The authors would like to thank Dave MacFarlane and Itxaso
Alayo for help in the management of the data extraction form
and data abstraction.
Financial support
This work was supported by the Instituto de Salud Carlos III
(ISCIII) (CD12/00440); ISCIII-FEDER (PI13/00343); ISCIII-
FIS (CM14/00125); Secretaria Nacional de Educaci
on Supe-
rior, Ciencia, Tecnolog
ıa e Innovaci

on (SENESCYT-Ecuador)
(A. MM.), ISCIII (ECA07/059); and AGAUR (AGAUR 2014
SGR 748).
Declaration of interest
There are no conflict of interests to be declared for all the
authors.
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Supporting Information
Additional Supporting Information may be found in the online
version of this article:
Fig. S1. Forest plot (a) and funnel plot (b) of childhood physi-
cal abuse (CPA) as a risk factor of suicide attempt.
Fig. S2. Forest plot (a) and funnel plot (b) of childhood sexual
abuse (CSA) as a risk factor of suicide attempt.
Fig. S3. Forest plot (a) and funnel plot (b) of childhood neglect
as a risk factor of suicide attempt.
Table S1. Typology and definition of interpersonal violence.
Table S2. MOOSE checklist.
Table S3. Quality of included articles.
Appendix S1. Search strategy and selection criteria of the
broader systematic review.
17