Perceived Family Support Buffers the Impact of PTSD-Depression Symptoms on Suicidal Ideation in College Students

Abstract

Students reporting symptoms of posttraumatic stress disorder (PTSD) and depression are at increased risk for suicidal ideation, putting them at greater risk for suicidal behavior and attempts. Perceived social support is a robust protective factor against the impact of PTSD and depression on suicidal ideation in college students, however different forms of social support (family, friends, significant others) may have greater influence on this association. In the current study, the influence of the different types of perceived social support on the relationship between PTSD-depression symptoms and suicidal ideation in college students were examined. College students (N = 928; 71% female) were recruited in part of a cross-sectional survey study examining the role of mental health on education functioning. A hierarchical regression indicated that PTSD-depression symptoms (b = .27, p < .001) and perceived family support (b = −.04, p < .01) were significantly associated with current suicidal ideation, while perceived support from friends (b = −.02, p = .417) and significant others (b = −.01, p = .301) were not. Perceived family support interacted with PTSD-depression symptoms (b = −.03, p < .05) to weaken the positive influence of symptoms on current suicidal ideation. Perceived family support appears to be the significant component of social support that moderates the relationship between PTSD-depression symptoms and suicidal ideation. Future research should focus on strengthening family support as a potential mechanism to mitigate suicide risk among college students who may be away from their families for the first time.

Keywords

Family social support posttraumatic stress disorder depression suicidal ideation

Introduction

Suicide is the second leading cause of death for college-aged adults in the United States (Heron, 2021), and one in five college students experience suicidal ideation within the past year (Liu et al., 2019). Meta-analytic data and systematic analyses of the literature indicate there is a robust association between posttraumatic stress disorder (PTSD), depression, and suicide risk in college students (Krysinska & Lester, 2010; Li et al., 2020). Further, students with PTSD and depression symptoms are more likely to have prior suicide attempts and greater suicidal ideation (Kratovic et al., 2021), and PTSD and depression are also associated with greater risk for engaging in future suicidal behavior (Schafer et al., 2021; Wilcox et al., 2010). These data are concerning given 70% of college students report experiencing a potentially traumatic event, and prevalence rates for PTSD within this group are as high as 34.4% (Cusack et al., 2019). Depression is also common among college students, with past-year prevalence rates as high as 18.5% (Auerbach et al., 2018), and frequently co-occurs with PTSD (Rytwinski et al., 2013).

Through the lens of the Interpersonal Psychological Theory of Suicide Behavior (IPTSB; Joiner et al., 2005), PTSD symptoms, specifically numbing and hyperarousal, are linked to higher perceived burdensomeness, thwarted belongingness, and fearlessness of death (Pennings et al., 2017). Further, emotional numbing symptoms of PTSD, specifically detachment and estrangement from others, are associated with greater suicidal ideation in college students, even after accounting for depression and other PTSD symptoms (Davis et al., 2014). Symptoms of depression are also linked to greater perceived burdensomeness and thwarted belonging, resulting in greater suicidal ideation (Kleiman, Riskind, et al., 2014). These findings indicate perceptions of interpersonal relationships play a key role in of the association between PTSD, depression, and suicidal ideation and behavior.

Indeed, perceived social support is a robust protective factor against suicide (Bryan & Hernandez, 2013; Du et al., 2021; Hirsch & Barton, 2011), as people with greater perceived social support are less likely to attempt suicide in their lifetime (Kleiman & Liu, 2013). Separate studies show social support also buffers the impact of PTSD and depression symptoms on suicidal ideation in college students (Kleiman, Liu, et al., 2014; Lamis et al., 2016), however different forms of social support may have greater influence on this association than others. Out of three main sources of perceived social support (family, friends, and significant others), increased family support has been found to be the only significant predictor of reduced suicidal ideation in college students (Olatunji et al., 2020) and young adults with major depressive disorder (Ashbaugh et al., 2016). It is currently unknown what specific forms of perceived social support influence the relationship between PTSD, depression symptoms, and suicidal ideation in college students. A greater understanding of perceived social support in a multi-faceted manner may inform future targeted prevention efforts, as college initiatives can help facilitate strengthening of certain social support systems for their students.

The purpose of the current study was to examine the relative influence of different forms of perceived social support on the association between PTSD-depression symptoms and suicidal ideation in college students. Consistent with the prior literature, it was hypothesized that both PTSD-depression symptoms and perceived social support from family, but not friends or significant others, would be associated with current levels of suicidal ideation. Moreover, it was hypothesized perceived family support would interact with PTSD-depression symptoms, in that high perceived family support would buffer the effects of high PTSD-depression symptoms on suicidal ideation, whereas low family support would intensify the relationship between PTSD-depression symptoms and suicidal ideation.

Method

Participants & Procedures

Undergraduate students (N = 1100) enrolled at The University of Texas at San Antonio were recruited through the psychology subject pool, other psychology courses, and across the university campus for a study examining the impact of mental health symptoms on academic success. Eligible students were at least 18 years of age and willing to allow researchers access to their academic transcripts. Participants who completed the study received one research credit hour, extra credit in an amount determined by their instructor, or a $10 Amazon gift card if recruited via advertisements posted on campus. In keeping with criteria from the Diagnostic and Statistical Manual for Mental Disorders, fifth Edition (DSM-5; American Psychiatric Association, 2013), only those who endorsed experiencing a traumatic event were included in the sample for the current study (n = 972), such that symptoms reported on the PTSD-Checklist for DSM-5 (PCL-5; Weathers, Litz et al., 2013) could be conceptualized as potential PTSD symptoms. As gender was a covariate for analyses, participants who identified as non-binary (n = 16) were excluded from analyses as there were an insufficient number to make an adequate comparison. Additional participants (n = 11) were excluded from analyses for missing data due to listwise deletion and for not following instructions in completing the survey (n = 17). The final sample included 928 participants.

Measures

Demographics

Demographic characteristics, including age, gender, race, ethnicity, and college classification level were assessed via self-report.

Potentially Traumatic Experiences and PTSD Symptoms

The Life Events Checklist (LEC-5; Weathers et al., 2013) was used to identify participants who had experienced potentially traumatic events. The LEC-5 contains 17 items describing distressing events (e.g., motor vehicle accident, natural disaster, sexual assault), and participants indicate how they have experienced each event by selecting 1 (Happened to me) to 6 (Does not apply). The scale has good convergent validity with other measures of trauma (Gray et al., 2004).

The PCL-5 consists of 20 items assessing the severity of PTSD symptoms according to DSM-5 criteria (Weathers, Litz et al., 2013). Participants rate the extent to which they were bothered by symptoms in the past month on a scale from 0 (Not at all) to 4 (Extremely). Example items include “Avoiding memories, thoughts, or feelings related to the stressful experience?”, “Trouble remembering important parts of the stressful experience?”, and “Being “superalert” or watchful or on guard?”. A total score ≥ 31 was used as a cut-off to determine probable PTSD (Ashbaugh et al., 2016). The scale has excellent psychometric properties within college students (Blevins et al., 2015). Cronbach’s alpha for the current study was .95.

Depression Symptoms

The Patient Health Questionnaire 9 (PHQ-9; Kroenke et al., 2001) contains nine items to assess depression symptom severity, where participants indicate symptoms experienced in the past 2 weeks. Example items include “Feeling down, depressed, or hopeless”, “Feeling tired or having little energy”, and “Little interest or pleasure in doing things”. Students with a total score ≥10 met criteria for probable depressive disorder (Manea et al., 2012). Item 9 (“Thoughts that you would be better off dead, or of hurting yourself”) was excluded to avoid overlap with the suicidal ideation outcome variable (r = .67, p < .001). Cronbach’s alpha for the 8-item scale in the current study was .91.

Social Support

The Multidimensional Scale for Perceived Social Support (MSPSS; Zimet et al., 1988) was used to assess the levels of perceived social support. The scale 12 items that assess perceived support from family, friends, and significant others, examples include “I can talk about my problems with my family,” “My friends really try to help me,” and “There is a special person in my life who cares about my feelings.”. Higher scores on each subscale indicate greater perceived social support. The subscales demonstrate an excellent internal consistency within college students (Ermis-Demirtas et al., 2018; Zimet et al., 1988), and Cronbach’s alphas for each of the subscales in the current study were .94 for family support, .94 for friend support, and .95 for significant other support.

Current Suicidal Ideation

The Depression Severity Index – Suicidality Subscale (DSI-SS; Joiner et al., 2002a, 2002b) self-report scale contains four items that describe thoughts, planning, and urges to attempt suicide in the past 2 weeks. Scores on each item range from 0 to 3, with greater scores indicating greater levels of suicidal ideation. Participants select the answer choice that applies to them; example choices include “I do not have thoughts of killing myself”, “Sometimes I have thoughts of killing myself”, “Most of the time I have thoughts of killing myself”, and “I always have thoughts of killing myself”. The scale has a good internal consistency (Joiner et al., 2002a, 2002b), and Cronbach’s alpha for the current study was .92.

Data Analysis

Analyses were conducted in SPSS version 25. Given that PTSD and depression symptoms were highly correlated in the current study (r = .68, p > .001), a composite factor for PTSD-depression symptoms was created using principal components analysis (PCA). The PCA results indicated PCL-5 and PHQ-9 total scores both loaded highly onto a single factor (.92 for both measures); factor scores were then used to represent PTSD-depression symptoms as a predictor in the hierarchical regression analysis (DeBeer et al., 2014). In addition, due to elevated skewness (2.48, SE = .08) and kurtosis (6.25, SE = .160) present in the distribution DSI-SS total scores, data were log-transformed. Continuous variables were mean-centered (with exception of the PTSD-depression factor scores), and interaction terms were derived from the product of PTSD-depression factor scores with each of the mean-centered MPSS subscale scores. Gender served as covariate to account gender differences in PTSD, depression symptoms, and suicidal ideation (Boyraz et al., 2015; Brownson et al., 2011).

Results

Demographics and characteristics of the sample (N = 928) are displayed in Table 1. The final model in the hierarchical regression accounted for approximately 29% of the variance in current suicidal ideation (see Table 2). In Step 1, female gender was initially associated with greater suicidal ideation (b = .14, p < .01), however, was not significant in subsequent steps. In Step 2, PTSD-depression symptoms were significantly associated with greater suicidal ideation (b = .32, p < .001). In Step 3, perceived family support (b = −.05, p < .001) was associated with greater current suicidal ideation, while perceived support from friends (b = −.01, p = .417) and significant others (b = −.015, p = .405) were not. Finally in Step 4, perceived family support interacted with PTSD-depression symptoms (b = −.03, p < .05; see Figure 1). Specifically, even in the context of high symptoms, participants with greater perceived family support reported lower levels of suicidal ideation compared to those with lower perceived family support and high symptoms, who had the strongest levels of SI. By contrast, the interaction terms for support from friends (b = −.01, p = .569) and significant others (b = −.01, p = .452) were not significant.

Table 1.

Sample Characteristics.

Variable	M (SD) or n (%)
Age	20.30 (4.31)
Gender
Female	667 (71.9%)
Male	261 (28.1%)
Hispanic or Latino (Yes)	563 (60.7%)
Race
American Indian/Alaskan native	25 (2.7%)
Asian	69 (7.4%)
Native Hawaiian/Pacific Islander	8 (0.9%)
African American	107 (11.5%)
White	649 (69.9%)
Other	70 (7.5%)
College classification
Freshman (0–29 semester credit hours)	449 (48.4%)
Sophomore (30–59 semester credit hours)	230 (24.8%)
Junior (60–89 semester credit hours)	115 (12.4%)
Senior (90 + semester credit hours)	134 (14.4%)
Mental health symptoms
PCL-5 total scores	25.32 (19.76)
PHQ-9 total scores	8.64 (6.83)
Mental health disorder and suicide risk
Probable MDD	359 (38.7%)
Probable PTSD	349 (37.6%)
Elevated risk for suicide^*	139 (15.0%)

Note. *Participants were considered at elevated risk for suicide when DSI-SS total scores were three or greater (Joiner et al., 2002a, 2002b).

Table 2.

Predictors of Suicidal Ideation Using Hierarchical Regression.

Independent Variable	Step 1			Step 2			Step 3			Step 4
Independent Variable	b	SE b	b*	b	SE b	b*	b	SE b	b*	b	SE b	b*
Gender	0.14	.045	.10^**	−0.03	.04	−.02	−0.02	.04	−.02	−0.03	.04	−.02
PTSD-depression symptoms				0.32	.02	.52^***	0.28	.02	.45^***	0.27	.02	.44***
Perceived support - family							−0.05	.01	−.12^***	−0.04	.01	−.11**
Perceived support - friends							−0.01	.01	−.03	−0.02	.02	−.04
Perceived support - significant							−0.01	.01	−.04	−0.01	.01	−.03
PTSD-depression x family										−0.03	.01	−.08*
PTSD-depression x friends										−0.01	.01	−.02
PTSD-depression x significant										−0.01	.01	−.03
Adjusted R²			.01			.26			.28			.29
ΔR²						.23			.02			.02
F of ΔR²			10.01^**			311.61^***			9.21^***			5.51^***

Note. Gender coded as Male = 1, Female = 2. Significant = Significant Others.

*p < .05, **p < .01, ***p ≤ .001.

Figure 1.

Plot depicting family support x PTSD-depression symptoms interaction predicting current suicidal ideation among college students. Note. Plot depicting family support x PTSD-depression symptoms interaction predicting current suicidal ideation among college students.

Discussion

The current study examined the protective influence of different subtypes of perceived social support on the association between PTSD-depression symptoms on current suicidal ideation in a diverse sample of college students. Results indicated that greater perceived family support was significantly associated with lower ideation, while perceived support from friends and significant others were not. This finding aligns with previous evidence that greater perceived family support is uniquely associated with lower suicidal ideation in college students (Olatunji et al., 2020).

Family support, but not other forms, also interacted with PTSD-depression symptoms. In the context of high PTSD-depression symptoms, students with greater perceived family support had lower suicidal ideation. By contrast, those with high PTSD-depression symptoms but low perceived family support had the highest suicidal ideation. Thus, perceived family support buffered the effects of PTSD-depression on suicidal ideation, suggesting this may be a key point of intervention for suicide prevention among college students. The results also provide additional evidence in support of clinical interventions built to target social impairments in persons with PTSD. For example, participation in Acceptance and Commitment Therapy to Improve Social Support in Veterans with PTSD (ACT-SS), a form of acceptance and commitment therapy specifically built to treat avoidance of social interactions and encourage acceptance of discomfort associated with social experiences, is associated with greater improvements in the quality of social relationships, engagement in social activities, and PTSD symptoms in comparison to participation in present-centered therapy (Kelly et al., 2022).

Perceived family support may be a unique protective factor due to possible differences in the stability of support, and other associated forms of support families can provide. Family support is often more consistent over a person’s lifetime, while relationships between friends and significant others may fluctuate for students entering college. Perceived family support could also be associated with greater financial support and reduced financial stress, as college student financial stress predicts increased odds of engaging in suicidal ideation, planning, and attempts (Assari, 2018). Families may also be able to provide tangible support more readily (i.e., access to material resources and handling of responsibilities), in turn buffering the influence of emotional distress on suicidal ideation (Bryan & Hernandez, 2013). Further research is needed to determine what properties of family support are key to influencing the relationship between mental health symptoms and suicidal ideation.

Perceived family support may be a strong protective factor given the current study’s predominately Hispanic sample. Hispanic and Latin people endorse greater familism (i.e., reverence of the family and emphasis on warm family relationships) than other ethnicities (Sabogal et al., 1987), and familism is associated with greater psychological health through greater perceived social support (Campos et al., 2014). Future research should assess how this cultural value interacts with perceived family support to influence PTSD-depression symptoms and suicidal ideation.

The current study addressed a critical gap in suicide literature by examining how subtypes of social support contributed to the relationship between PTSD-depression symptoms and suicidal ideation. In addition, the study findings have greater generalizability via using an ethnically diverse sample of college students, particularly to Hispanic and Latin college students. This study is not without limitations. These include the reliance on self-report measures in assessing mental health symptoms rather than diagnostic interviews. Further, the cross-sectional nature of the study limits inferences on causality in the relationship between PTSD-depression symptoms and suicidal ideation. Further, although suicidal ideation is highly associated with suicidal attempts (McHugh et al., 2019), suicidal attempts were not assessed. Extensions of this work would benefit from observing how fluctuations in perceived family support influence the relationship between mental health and suicidal ideation and behavior over students’ academic careers.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by the the University of Texas at San Antonio, Office of the Vice President for Research, Economic Development, and Knowledge Enterprise (Internal Research Award (NTRA)).

ORCID iD

Alexis Blessing

Author Biographies

Alexis Blessing is a psychologist and Assistant Professor of Research in the Department of Psychology at the University of Texas at San Antonio.

Patricia D. Russell is a psychologist and Health Science Specialist within the VA Rocky Mountain Mental Illness, Research, Education, and Clinical Center (MIRECC) for Suicide Prevention.

Bryann B. DeBeer is a clinical research psychologist within the VA Rocky Mountain Mental Illness, Research, Education, and Clinical Center (MIRECC) for Suicide Prevention and Director of the VA Patient Safety Center of Inquiry - Suicide Prevention Collaborative. Dr. DeBeer is also an Associate Professor in the Department of Physical Medicine and Rehabilitation at the University of Colorado Anschutz Medical Campus.

Sandra B. Morissette is a clinical psychologist, Professor, and Department Chair in the Department of Psychology at the University of Texas at San Antonio. Dr. Morissette is also the Director of the Trauma Health in Veterans’ Experiences (THRIVE) Laboratory.

References

American Psychiatric Association . (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596

Ashbaugh

A. R.

Houle-Johnson

Herbert

El-Hage

Brunet

(2016). Psychometric validation of the English and French Versions of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). PLOS ONE, 11(10), e0161645. https://doi.org/10.1371/journal.pone.0161645

Assari

(2018). Multiplicative effects of social and psychological risk factors on college students’ suicidal behaviors. Brain Sciences, 8(5), 91. https://doi.org/10.3390/brainsci8050091

Auerbach

R. P.

Mortier

Bruffaerts

Alonso

Benjet

Cuijpers

Demyttenaere

Ebert

D. D.

Green

J. G.

Hasking

Murray

Nock

M. K.

Pinder-Amaker

Sampson

N. A.

Stein

D. J.

Vilagut

Zaslavsky

A. M.

Kessler

R. C.

WHO WMH-ICS Collaborators . (2018). WHO world mental health surveys International College student project: Prevalence and distribution of mental disorders. Journal of Abnormal Psychology, 127(7), 623–638. https://doi.org/10.1037/abn0000362

Blevins

C. A.

Weathers

F. W.

Davis

M. T.

Witte

T. K.

Domino

J. L.

(2015). The posttraumatic stress disorder checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489–498. https://doi.org/10.1002/jts.22059

Boyraz

Horne

S. G.

Armstrong

A. P.

Owens

A. C.

(2015). Posttraumatic stress predicting depression and social support among college students: Moderating effects of race and gender. Psychological Trauma: Theory, Research, Practice, and Policy, 7(3), 259–268. https://doi.org/10.1037/a0037967

Brownson

Drum

D. J.

Smith

S. E.

Burton Denmark

(2011). Differences in suicidal experiences of male and female undergraduate and graduate students. Journal of College Student Psychotherapy, 25(4), 277–294. https://doi.org/10.1080/87568225.2011.605692

Bryan

C. J.

Hernandez

A. M.

(2013). The functions of social support as protective factors for suicidal ideation in a sample of air force personnel. Suicide and Life-Threatening Behavior, 43(5), 562–573. https://doi.org/10.1111/sltb.12039

Campos

Ullman

J. B.

Aguilera

Dunkel Schetter

(2014). Familism and psychological health: The intervening role of closeness and social support. Cultural Diversity and Ethnic Minority Psychology, 20(2), 191–201. https://doi.org/10.1037/a0034094

10.

Cusack

S. E.

Hicks

T. A.

Bourdon

Sheerin

C. M.

Overstreet

C. M.

Kendler

K. S.

Dick

D. M.

Amstadter

A. B.

(2019). Prevalence and predictors of PTSD among a college sample. Journal of American College Health, 67(2), 123–131. https://doi.org/10.1080/07448481.2018.1462824

11.

Davis

M. T.

Witte

T. K.

Weathers

F. W.

(2014). Posttraumatic stress disorder and suicidal ideation: The role of specific symptoms within the framework of the interpersonal-psychological theory of suicide. Psychological Trauma: Theory, Research, Practice, and Policy, 6(6), 610–618. https://doi.org/10.1037/a0033941

12.

DeBeer

B. B.

Kimbrel

N. A.

Meyer

E. C.

Gulliver

S. B.

Morissette

S. B.

(2014). Combined PTSD and depressive symptoms interact with post-deployment social support to predict suicidal ideation in operation enduring freedom and operation Iraqi freedom veterans. Psychiatry Research, 216(3), 357–362. https://doi.org/10.1016/j.psychres.2014.02.010

13.

Shi

H. Y.

Qian

Jin

X. H.

H. R.

Liu

X. M.

X. L.

Chen

H. L.

(2021). Association between social support and suicidal ideation in patients with cancer: A systematic review and meta-analysis. European Journal of Cancer Care, 30(2), e13382. https://doi.org/10.1111/ecc.13382.

14.

Ermis-Demirtas

Watson

J. C.

Karaman

M. A.

Freeman

Kumaran

Haktanir

Streeter

A. M.

(2018). Psychometric properties of the multidimensional scale of perceived social support within Hispanic college students. Hispanic Journal of Behavioral Sciences, 40(4), 472–485. https://doi.org/10.1177/0739986318790733

15.

Gray

M. J.

Litz

B. T.

Hsu

J. L.

Lombardo

T. W.

(2004). Psychometric properties of the life events checklist. Assessment, 11(4), 330–341. https://doi.org/10.1177/1073191104269954

16.

Heron

M. P.

(2021). Deaths: Leading causes for 2018 (National Vital Statistics Reports vol 70, Issue 4). National Center for Health Statistics (U.S.). Division of Vital Statistics. https://stacks.cdc.gov/view/cdc/104186

17.

Hirsch

J. K.

Barton

A. L.

(2011). Positive social support, negative social exchanges, and suicidal behavior in college students. Journal of American College Health, 59(5), 393–398. https://doi.org/10.1080/07448481.2010.515635

18.

Joiner

T. E.

Brown

J. S.

Wingate

L. R.

(2005). The psychology and neurobiology of suicidal behavior. Annual Review of Psychology, 56(1), 287–314. https://doi.org/10.1146/annurev.psych.56.091103.070320

19.

Joiner

T. E.

Pfaff

J. J.

Acres

J. G.

(2002a). A brief screening tool for suicidal symptoms in adolescents and young adults in general health settings: Reliability and validity data from the Australian National General Practice Youth Suicide Prevention Project. Behaviour Research and Therapy, 40(4), 471–481. https://doi.org/10.1016/S0005-7967(01)00017-1

20.

Joiner

T. E.

Pfaff

J. J.

Acres

J. G.

(2002b). Characteristics of suicidal adolescents and young adults presenting to primary care with non-suicidal (indeed non-psychological) complaints. European Journal of Public Health, 12(3), 177–179. https://doi.org/10.1093/eurpub/12.3.177

21.

Kelly

M. M.

Reilly

E. D.

Ameral

Richter

Fukuda

(2022). A randomized pilot study of acceptance and commitment therapy to improve social support for veterans with PTSD. Journal of Clinical Medicine, 11(12), 3482. https://doi.org/10.3390/jcm11123482

22.

Kleiman

E. M.

Liu

R. T.

(2013). Social support as a protective factor in suicide: Findings from two nationally representative samples. Journal of Affective Disorders, 150(2), 540–545. https://doi.org/10.1016/j.jad.2013.01.033

23.

Kleiman

E. M.

Liu

R. T.

Riskind

J. H.

(2014). Integrating the interpersonal psychological theory of suicide into the depression/suicidal ideation relationship: A short-term prospective study. Behavior Therapy, 45(2), 212–221. https://doi.org/10.1016/j.beth.2013.10.007

24.

Kleiman

E. M.

Riskind

J. H.

Schaefer

K. E.

(2014). Social support and positive events as suicide resiliency factors: Examination of synergistic buffering effects. Archives of Suicide Research, 18(2), 144–155. https://doi.org/10.1080/13811118.2013.826155

25.

Kratovic

Smith

L. J.

Vujanovic

A. A.

(2021). PTSD symptoms, suicidal ideation, and suicide risk in university students: The role of distress tolerance. Journal of Aggression, Maltreatment & Trauma, 30(1), 82–100. https://doi.org/10.1080/10926771.2019.1709594

26.

Kroenke

Spitzer

R. L.

Williams

J. B. W.

(2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

27.

Krysinska

Lester

(2010). Post-traumatic stress disorder and suicide risk: A systematic review. Archives of Suicide Research: Official Journal of the International Academy for Suicide Research, 14(1), 1–23. https://doi.org/10.1080/13811110903478997

28.

Lamis

D. A.

Ballard

E. D.

May

A. M.

Dvorak

R. D.

(2016). Depressive symptoms and suicidal ideation in college students: The mediating and moderating roles of hopelessness, alcohol problems, and social support. Journal of Clinical Psychology, 72(9), 919–932. https://doi.org/10.1002/jclp.22295

29.

Dorstyn

D. S.

Jarmon

(2020). Identifying suicide risk among college students: A systematic review. Death Studies, 44(7), 450–458. https://doi.org/10.1080/07481187.2019.1578305

30.

Liu

C. H.

Stevens

Wong

S. H. M.

Yasui

Chen

J. A.

(2019). The prevalence and predictors of mental health diagnoses and suicide among U.S. college students: Implications for addressing disparities in service use. Depression and Anxiety, 36(1), 8–17. https://doi.org/10.1002/da.22830

31.

Manea

Gilbody

McMillan

(2012). Optimal cut-off score for diagnosing depression with the patient health questionnaire (PHQ-9): A meta-analysis. Canadian Medical Association Journal, 184(3), E191–E196. https://doi.org/10.1503/cmaj.110829

32.

McHugh

C. M.

Corderoy

Ryan

C. J.

Hickie

I. B.

Large

M. M.

(2019). Association between suicidal ideation and suicide: Meta-analyses of odds ratios, sensitivity, specificity and positive predictive value. BJPsych Open, 5(2), e18. https://doi.org/10.1192/bjo.2018.88

33.

Olatunji

O. A.

Idemudia

E. S.

Olawa

B. D.

(2020). Family support, self-efficacy and suicidal ideation at emerging adulthood: A mediation analysis. International Journal of Adolescence and Youth, 25(1), 920–931. https://doi.org/10.1080/02673843.2020.1779762

34.

Pennings

S. M.

Finn

Houtsma

Green

B. A.

Anestis

M. D.

(2017). Posttraumatic stress disorder symptom clusters and the interpersonal theory of suicide in a large military sample. Suicide and Life-Threatening Behavior, 47(5), 538–550. https://doi.org/10.1111/sltb.12317

35.

Rytwinski

N. K.

Scur

M. D.

Feeny

N. C.

Youngstrom

E. A.

(2013). The co-occurrence of major depressive disorder among individuals with posttraumatic stress disorder: A meta-analysis. Journal of Traumatic Stress, 26(3), 299–309. https://doi.org/10.1002/jts.21814

36.

Sabogal

Marín

Otero-Sabogal

Marín

B. V.

Perez-Stable

E. J.

(1987). Hispanic familism and acculturation: What changes and what doesn’t? Hispanic Journal of Behavioral Sciences, 9(4), 397–412. https://doi.org/10.1177/07399863870094003

37.

Schafer

K. M.

Clancy

K. J.

Joiner

(2021). An investigation into the bidirectional relationship between post-traumatic stress disorder and suicidal ideation: A nine year study. Journal of Anxiety Disorders, 85(102510), 102510. https://doi.org/10.1016/j.janxdis.2021.102510

38.

Weathers

F. W.

Blake

D. D.

Schnurr

P. P.

Kaloupek

D. G.

Marx

B. P.

Keane

T. M.

(2013). The life events checklist for DSM-5 (LEC-5). Scale available from the National Center for PTSD at: www.ptsd.va.gov

39.

Weathers

F. W.

Litz

B. T.

Keane

T. M.

Palmieri

P. A.

Marx

B. P.

Schnurr

P. P.

(2013). The PTSD checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at: www.ptsd.va.gov

40.

Wilcox

H. C.

Arria

A. M.

Caldeira

K. M.

Vincent

K. B.

Pinchevsky

G. M.

O’Grady

K. E.

(2010). Prevalence and predictors of persistent suicide ideation, plans, and attempts during college. Journal of Affective Disorders, 127(1–3), 287–294. https://doi.org/10.1016/j.jad.2010.04.017

41.

Zimet

G. D.

Dahlem

N. W.

Zimet

S. G.

Farley

G. K.

(1988). The multidimensional scale of perceived social support. Journal of Personality Assessment, 52(1), 30–41. https://doi.org/10.1207/s15327752jpa5201_2