Recently, an important study was published that examined bullying and its potential association with depression and suicidal behavior in adolescents.1 A unique feature of this study was that it assessed bullying behavior and suicide attempts in victims of bullying, persons who exhibited bullying behavior, and bully-victims (adolescents who were bullies and victims of bullying). In addition, the study examined bullying behavior both in and out of school settings.
Adolescents aged 13 to 19 years who were enrolled in grades 9 through 12 in suburban schools in New York were included. A total of 2341 students who attended school from fall 2002 to spring 2004 completed a questionnaire; the sample was predominantly white (80%) and 58% were male.
The questions related to the 4 weeks before the study, although the reporting period for suicide attempts was lifetime. Researchers used the Beck Depression Inventory to assess depression and the Suicide Ideation Questionnaire to asess suicidal ideation. Suicide attempt history included any attempt, regardless of extent of injury.
With regard to bullying behavior, students were asked how often they had been bullied or had bullied others in and out of school during the past 4 weeks. "Being bullied" was defined as having student(s) say or do unpleasant things or being teased repeatedly in a way the person does not like.
About 20% of students reported that they were victims of bullying in school and about 10% reported that they were victims of bullying outside school. With regard to bullying behavior, about 25% of students reported that they bullied other students in school and 15% reported that they bullied others outside school.
These percentages of bullying behaviors are quite high, particularly since the time frame for reporting these events was only 4 weeks. Boys were more likely than girls to be vic- tims of bullying in school, whereas boys and girls were equally likely to be victims of bullying outside school.
The risk of depression, suicidal ideation, and suicide attempt was significantly higher for students who were considered either a victim or a bully compared with students who were not. This association was noted whether bullying behavior occurred in or out of school. The more frequent the bullying behavior (either as a victim or bully), the greater the risk of depression, suicidal ideation, or suicide attempt.
For example, adolescents who were frequent victims of bullying in school were 5 times as likely to have serious suicidal ideation and 4 times as likely to attempt suicide as students who had not been victims. Similarly, students who frequently bullied others in school were 3 times as likely to have serious suicidal ideation and suicide attempts as those who did not bully others in school and were 5 times as likely to have serious suicidal ideation and suicide attempts as those who did not bully others outside of school.
Even when bullying was infrequent (less than weekly), the likelihood of suicidal behavior was about 2 times greater in both victims and bullies in and out of school than in those who were not bullied. Students who were considered to be bully-victims frequently were at the highest risk for depression and suicidal behavior.
The authors of the article concluded that bullying might be a marker of suicidal behavior. They recommended that prevention of bullying should be part of suicide prevention efforts. A relevant component of this study was that it examined bullying behavior outside the school setting. Although bullying behavior (as the victim or bully) was found to be more common in school than it was outside school, it is important to note that this study was conducted from 2002 to 2004. With the burgeoning use of cyberspace, it would be interesting to learn whether the frequency of reported bullying outside school has increased.
In 2001, I wrote a column "Too Much Bullying in Our Schools" (Psychiatric Times, September 2001, page 21); since then, the Internet and cell phones have, unfortunately, provided increased opportunities for bullying outside school that do not require face-to-face confrontation.
Recent news has focused on the rise of cyber-bullying. For example, in a Google search of bullying and cyberspace in January 2007, there were 278,000 citations. Whereas bullying in school is restricted to students in that school, the Internet provides access to nearly limitless numbers of people. Many teenagers are adept at text messaging on cell phones, creating Web sites and blogs, instant messaging, and creating videos that can be transmitted instantly. Poignant stories have been written about teenagers who were victims of cyber-bullying and felt that aspects of their lives were ruined by this experience.2,3
The seriousness of bullying, particularly as it relates to suicidal behavior, is exemplified in the findings from the survey described.1 It is important for clinicians to be aware of the high prevalence of bullying behavior (either as victim, bully, or both) in adolescents. Moreover, students who are bullied in school may not be able to escape the bullying when they are at home because of current communications technology.
Clinicians should inquire about bullying when evaluating and treating teenagers, especially those who have depression. Similarly, clinicians should inform parents about the serious clinical implications of bullying and recommend that they talk with their teenager about the bullying behavior that may be occurring both in and outside school.
