Depressive symptoms co-occurring with forced sexual intercourse, bullying, or substance use are associated with super-additive suicide-attempt prevalence among U.S. adolescents

Depression screening is central to adolescent suicide prevention, yet depression alone may not identify adolescents with particularly high suicide-attempt prevalence when violence, bullying, or substance use is also reported. We conducted a pooled cross-sectional analysis of nationally representative 2019, 2021, and 2023 U.S. Youth Risk Behavior Survey data (n = 51,012) using survey-weighted regression with 50 multiply imputed datasets.

Additive interaction was estimated using population-average adjusted risks. Interaction contrasts (ICs, percentage points) were positive for forced sexual intercourse (16.596, 95% CI 12.004–21.188), cyberbullying (11.898, 9.424–14.371), substance use (11.194, 8.942–13.445), and school bullying (10.168, 7.643–12.693). Adjusted risks in the joint-indicator groups ranged from 27.531% for substance use to 42.283% for forced sexual intercourse.

Mutually adjusted ICs remained positive (range 2.831–9.351% points). Multiplicative interaction was supported for substance use and forced sexual intercourse in separate models, but only for substance use in the mutually adjusted model. These co-occurring indicators warrant prospective evaluation.

Temporal ordering and causal mechanisms remain unresolved. Centers for disease control and prevention School of Public Administration, Sichuan University, Chengdu, 610065, China School of Economics and Management, Harbin Engineering University, Harbin, 150001, China Faculty of Social Sciences and Humanities, Kyrgyz National University Named After Jusup Balasagyn, Bishkek, 720033, Kyrgyzstan The authors declare no competing interests. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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