Journal of Affective Disorders 209 (2017) 53–58

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Journal of Affective Disorders

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Research paper Menarche, menstrual problems and suicidal behavior in Chinese adolescents crossmark

Hua Chena, Xin-Ting Wanga, Qi-Gui Bob, Dao-Ming Zhangc, Zhen-Biao Qid, Xianchen Liua,e, ⁎ Cun-Xian Jiaa, a Department of Epidemiology, University School of Public Health & Shandong University Center for Suicide Prevention Research, , b Centers for Disease Control and Prevention of Lijin County, Lijin, China c Centers for Disease Control and Prevention of Yanggu County, Yanggu, China d Centers for Disease Control and Prevention of County, Zoucheng, China e The University of Tennessee Health Science Center, Memphis, TN, USA

ARTICLE INFO ABSTRACT

Keywords: Background: Menarche is the first menstrual cycle. Menstrual problems, such as dysmenorrheal menorrhagia, Suicide oligomenorrhea, and irregular cycle are common in female adolescents. This research aims to examine the Menstruation associations between age at menarche and menstrual problems and suicidal behavior among Chinese female Menarche adolescents. Adolescents Methods: An epidemiological survey of 5831 female adolescents from eight high schools of three counties of Shandong province, China, was conducted. A self-administered paper-and-pencil questionnaire was used to collect information. Logistic regression analyses were used to examine the association between menstruation and suicidality. Results: The mean age of the sample was 15.02 (SD=1.44) years. Of the sample, 5,231 (90.0%) had experienced their first menstrual cycle, and 23.2%, 10.4%, and 4.5% of the sample reported having had suicidal ideation, plan and attempt, respectively. In multivariate models, menarche at ≤11 years was associated with increased risk of suicidal ideation (OR=1.41, 95%CI: 1.10–1.81) and menarche at 12 years was associated with suicide plan (OR=1.23, 95%CI: 1.00–1.51). Irregular menstrual cycle was significantly associated with increased risk of suicidal ideation (OR=1.40, 95%CI: 1.05–1.86) and menstrual period less than or equal to 4 days was significantly associated with increased risk of suicide plan (OR=1.32, 95%CI: 1.06–1.66). Limitations: This cross-sectional study cannot establish the causal directions between menstrual problems and suicidality in adolescents. Conclusions: Our study suggests that earlier menarche, irregular menstrual cycle and short menstrual period are associated with suicidal behavior in female adolescents. Further research is warranted to examine the causal relationship between menstrual problems and suicidal behavior in adolescents.

1. Introduction menarche has an impact on adolescents depression (Black and Klein, 2012). Menstrual problems are very common in adolescent girls, Adolescence is an important period, in which the girls go through including dysmenorrheal, heavy bleeding, oligomenorrhea, amenor- the critical changes of both physiology and psychology (Ravi et al., rhea, menorrheagia, and irregular cycle (Nur Azurah et al., 2013; Ravi 2015). Menarche is a vital milestone marking the maturation of et al., 2015). A study based on a sample of 3783 adolescents in Italy reproductive system for women, which is one of the most important shows that the prevalence of irregular length is 8.3% (De Sanctis et al., changes happening during adolescence for the females (Ajah et al., 2014). Menstrual problems can impact quality of life and increase risk 2015). Age at menarche has advanced in the last 3 decades. For of mental health problems (Nur Azurah et al., 2013). Besides, the example, the mean age at menarche fell from 13.41 years to 12.47 years experience of adolescence, like emotion abuse and emotional neglect, in China from 1985 to 2010 (Song et al., 2014). Similar tendency has physical abuse, and sexual abuse, is associated with Premenstrual been observed in other countries (Hosokawa et al., 2012). Early Dysphoric Disorder (PMDD) of adult females (Soydas et al., 2014).

⁎ Correspondence to: Department of Epidemiology, Shandong University School of Public Health, No. 44, Wenhuaxi Road, , Jinan 250012, China. E-mail address: [email protected] (C.-X. Jia). http://dx.doi.org/10.1016/j.jad.2016.11.027 Received 24 September 2016; Received in revised form 29 October 2016; Accepted 16 November 2016 Available online 20 November 2016 0165-0327/ © 2016 Elsevier B.V. All rights reserved. H. Chen et al. Journal of Affective Disorders 209 (2017) 53–58

Table 1 Suicidal behavior in a sample of Chinese female adolescents (N=5831).

Age, n (%) χ2 P

Overall n (%) ≤12 (n=247) 13–14 (n=1681) 15–16 (n=3138) ≥17 (n=747)

Suicidal Ideation 1351 (23.2) 19 (7.7) 250 (14.9) 888 (28.3) 194 (26.0) 147.578 < 0.01 Suicidal Plan 607 (10.4) 13 (5.3) 119 (7.1) 387 (12.3) 88 (11.8) 40.838 < 0.01 Suicidal attempt 259 (4.5) 4 (1.6) 45 (2.7) 173 (5.5) 37 (5.0) 25.836 < 0.01

Table 2 Demographic and psychosocial variables associated with suicidal ideation and plan or attempt in a sample of Chinese female adolescents (N=5831).

Suicidal ideation Suicide plan Suicide attempt

Overall, n (%) n (%) OR (95%CI) n (%) OR (95%CI) n (%) OR (95%CI)

Age ≤12 247 (4.2) 19 (7.7) 1.00 13 (5.3) 1.00 4 (1.6) 1.00 13–14 1681 (28.9) 250 (14.9) 2.10 (1.29–3.41) 119 (7.1) 1.37 (0.76–2.47) 45 (2.7) 1.67 (0.60–4.69) 15–16 3138 (54.0) 888 (28.3) 4.74 (2.95–7.61) 387 (12.3) 2.53 (1.43–4.47) 173 (5.5) 3.55 (1.30–9.63) ≥17 747 (12.9) 194 (26.0) 4.21 (2.56–6.91) 88 (11.8) 2.40 (1.32–4.39) 37 (5.0) 3.17 (1.12–8.97)

Internalizinga < 10 2860 (49.2) 308 (10.8) 1.00 114 (4.0) 1.00 56 (2.0) 1.00 10–17 1650 (28.4) 407 (24.7) 2.71 (2.31–3.19) 174 (10.5) 2.84 (2.22–3.63) 62 (3.8) 1.96 (1.36–2.82) > 17 1303 (22.4) 636 (48.8) 7.90 (6.73–9.28) 319 (24.5) 7.81 (6.23–9.79) 141 (10.8) 6.08 (4.43–8.34)

Externalizingb < 6 2567 (44.2) 274 (10.7) 1.00 95 (3.7) 1.00 41 (1.6) 1.00 6–11 1902 (32.7) 437 (23.0) 2.50 (2.12–2.94) 189 (9.9) 2.87 (2.23–3.70) 70 (3.7) 2.35 (1.59–3.47) > 11 1344 (23.1) 640 (47.6) 7.61 (6.45–8.87) 323 (24.0) 8.23 (6.48–10.47) 148 (11.0) 7.62 (5.36–10.85)

BHSc score ≤4 3529 (60.7) 616 (17.5) 1.00 257 (7.3) 1.00 111 (3.1) 1.00 5 629 (10.8) 157 (25.0) 1.57 (1.28–1.92) 69 (11.0) 1.57 (1.19–2.08) 28 (4.5) 1.43 (0.94–2.19) ≥6 1655 (28.5) 578 (34.9) 2.54 (2.22–2.90) 281 (17.0) 2.61 (2.17–3.12) 120 (7.3) 2.41 (1.85–3.14)

Substance use Smoking 620 (10.7) 323 (52.1) 4.41 (3.71–5.23) 170 (27.4) 4.11 (3.36–5.03) 83 (13.4) 4.41 (3.34–5.81) Alcohol use 1475 (25.4) 609 (41.3) 3.41 (2.99–3.88) 289 (19.6) 3.09 (2.59–3.66) 144 (9.8) 3.97 (3.09–5.12)

Numbers of Friends ≤2 770 (13.3) 271 (35.2) 2.18 (1.84–2.58) 125 (16.2) 2.02 (1.61–2.52) 64 (8.3) 2.08 (1.54–2.83) 3–4 1612 (27.7) 396 (24.6) 1.31 (1.14–1.51) 181 (11.2) 1.32 (1.08–1.60) 52 (3.2) 0.77 (0.56–1.06) ≥5 3431 (59.0) 684 (19.9) 1.00 301 (8.8) 1.00 143 (4.2) 1.00

Marital status of parents Very harmonious /harmonious 3990 (68.6) 747 (18.7) 1.00 303 (7.6) 1.00 138 (3.5) 1.00 Sometimes/often having trouble 1582 (27.2) 515 (32.6) 2.10 (1.84–2.39) 264 (16.7) 2.43 (2.04–2.91) 97 (6.1) 1.82 (1.40–2.38) Separated/divorced/a parent died 241 (4.2) 89 (36.9) 2.54 (1.93–2.24) 40 (16.6) 2.42 (1.69–3.47) 24 (10.0) 3.09 (1.96–4.86)

Family economy Very good/good 1007 (17.3) 172 (17.1) 1.00 99 (9.8) 1.00 48 (4.8) 1.00 Medium 4161 (71.6) 859 (23.0) 1.45 (1.22–1.74) 409 (9.8) 1.00 (0.79–1.26) 176 (4.2) 0.88 (0.64–1.22) Bad/very bad 645 (11.1) 220 (34.1) 2.51 (1.99–3.17) 99 (15.3) 1.66 (1.23–2.24) 35 (5.4) 1.15 (0.73–1.79)

a 10 was the 50th percentiles and 17was the 75th percentiles of the score of internalizing. Suicidal items in youth self-report were excluded internalizing. b 6 was the 50th percentiles and 11 was the 75th percentiles of the score of externalizing. c BHS=Beck Hopelessness Scale. 4 was the 50th percentiles and 6 was the 75th percentiles of the score of BHS.

Suicide is a common death cause worldwide and there were more high agreement on adolescent emotional and behavior problems, which than 800,000 deaths in 2012. Suicide is the second leading cause of are very common psychological problems among Chinese adolescents death globally in the age of 15–29 (World Health Organization, 2014). (Wang et al., 2014). For female adolescents, advancing age, living Suicidal behavior is prevalent among youths, especially in female without their parents, having depression, poor self-reported health, adolescents, and is a significant predictor of future suicide attempt drug abuse, sexual coitus, and expressing about unhappiness, suicidal and suicide death (King et al., 2014). Among adolescents many factors ideation and plan can increase the risk of suicide attempt (Chin and including female gender, advancing age, parents’ divorce/widow, and Choi, 2015; Cluver et al., 2015). Suicide risk begins to increases in the mood disorders can increase possibility of suicide attempt (Cluver early adolescence around menarche. However, little is known about the et al., 2015; Park et al., 2015). Many psychological factors, like the association between age at menarche and menstrual problems and behavioral problems and hopelessness, are associated with adolescent suicidal behavior in adolescents. suicidal behavior (Kovess-Masfety et al., 2015; Shilubane et al., 2013). To our knowledge, only a couple of studies have examined the Whether the using the checklist completed by parents or self-report by relationship between menstruation and suicidal behavior (Baca-Garcia the adolescents, it suggests that Chinese parents and adolescents have et al., 2004; Pilver et al., 2013), but it is not conclusive. PMDD was

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