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Klomek, A. B., Marracco, F., Kleinman, M., Schonfeld, I.S., & Gould, M.S. (2007). Bullying, depression, and suicidality in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 40–49.

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Nearly one third of 6th through 10th graders in the United States report moderate or frequent involvement in bullying, whether as a bully (13.0%), a victim (10.6%), or both (6.3%; Nansel et al., 2001). Although bullying behavior declines as children get older (Olweus, 1991), it is still a prevalent problem among high school students (e.g., Kaltiala-Heino et al., 1999; Nansel et al., 2001). Harris (2005) found that 20% to 30% of the students in grades 8 through 12 report frequent involvement in bullying incidents as either a victim or a bully. In studies examining the relationship between bullying and depression, victims were found to manifest more depressive symptoms and psychological distress than nonvictims (Hawker and Boulton, 2000; Kumpulainen and Rasanen, 2000; Kumpulainen et al., 1998; Mills et al., 2004; Neary and Joseph, 1994; Slee, 1995; van der Wal et al., 2003; Williams et al., 1996). Some studies did not find an association between being a bully and depression (Camodeca and Goossens, 2005; Fekkes et al., 2004; Juvonen et al., 2003), whereas other studies have found that bullies, not just victims, report high levels of depression (Forero et al., 1999; Kaltiala-Heino et al., 1999; Kaltiala-Heino et al., 2000; Kumpulainen et al., 2000; Roland, 2002; Salmon et al., 1998). Those who are both victims and bullies are usually found to be at the highest risk for depression (Fekkes et al., 2004; Kaltiala-Heino et al., 1999; Kaltiala-Heino et al., 2000).Victims manifest higher levels of suicidal ideation than nonvictims (Rigby and Slee, 1999; van der Wal et al., 2003). They are also more likely to attempt suicide (Cleary, 2000; Eisenberg et al., 2003; Mills et al., 2004). The purpose of this study was to examine the association between bullying behavior and depression, suicidal ideation, and suicide attempts among high school students. The researchers hypothesized that greater exposure to bullying behavior would increase the risk of depression, suicidal ideation, and suicide attempts.

Method: The study targeted adolescents 13 through 19 years of age who were enrolled in 9th through 12th grades in six high schools in New York. This study included 2,341 students, and 58.1% of the students were boys. A self-report questionnaire assessed depression, suicidal ideation, suicide attempts, and involvement in bullying behavior both as a bully and as a victim. The Beck Inventory (BDI-IA; Beck and Steer, 1993) assessed cognitive, behavioral, affective, and somatic components of depression. Each response ranged from 0 (‘‘symptoms not present’’) to 3 (‘‘symptom is severe’’), with a maximum total score of 60. The Suicide Ideation Questionnaire (SIQ-JR) is a 15-item survey that uses a 7-point Likert-type scale, ranging from 0 (‘‘I never had this thought’’) to 6 (‘’This thought was in my mind almost every day’’), assessing the frequency of specific suicidal thoughts during the past month. Suicidal ideation was considered serious if the adolescent scored 31 or higher on the SIQ-JR, scored 5 or 6 on two or more of the six ‘‘critical’’ SIQ-JR items (Reynolds, 1988), or responded with either of the two most serious response options of the BDI suicide item. Seven questions asking about lifetime and recent suicide attempts were derived from the depression module of the Diagnostic Interview Schedule for Children (Shaffer et al., 2000). Several questions regarding bullying behavior were derived from the World Health Organization study on youth health (Nansel et al., 2001). Questions about bullying were preceded with the following explanation: ‘‘We say a student is being bullied when another student or group of students says or does nasty and unpleasant things to him or her. It is also bullying when a pupil is teased repeatedly in a way he or she doesn`t like. But it is not bullying when two students of about the same strength quarrel or fight.’’ Victimization was assessed by two questions, ‘‘How often have you been bullied in school in the past four weeks?’’ and ‘‘How often have you been bullied away from school in the past four weeks?’’ The frequency items were coded on a five-point scale ranging from not at all to most days. Respondents were classified as ‘‘never victimized,’’ ‘‘victimized less than weekly,’’ or ‘‘victimized frequently (at least three to four times in the past 4 weeks). Similarly respondents were classified as ‘‘never bullying,’’ ‘‘bullying less than weekly,’’ or ‘‘bullying frequently.’’

Results: Victimization was more prevalent in school compared with away from school. Approximately 20% of the students reported being victims in school. Significantly fewer (10.4%) reported being victims away from school. Similarly, around 25% of the students reported bullying in school, whereas significantly fewer (around 15%) reported bullying away from school. Boys were significantly more likely than girls to be victims in school and to be bullies in and away from school. Students, who were involved in bullying behavior in or out of school, whether as a victim or a bully, were at significantly higher risk for depression, serious suicidal ideation, and suicide attempts compared with students who were never victims or bullies. The more frequent the involvement in bullying behavior was, the more likely the student was depressed, had SSI, or had attempted suicide; they were seven times more likely to be depressed compared with students who were never victims. Students who were victims were two to three times more likely to be depressed. Students who frequently bullied others were three times more likely to be depressed. Students who bullied others infrequently were two times more likely to be depressed. Frequently victimized boys were more likely to be depressed, have SSI, and attempt suicide than boys who were never victimized; boys who were infrequently victimized were more likely to attempt suicide but were not more likely to be depressed or have SSI than boys who were never victimized. Boys who bullied others frequently were more likely to be depressed and have SSI but were not more likely to attempt suicide compared with boys who never bullied others. Boys who bullied others infrequently were not at a higher risk for depression, SSI, or suicide attempts. Among girls, any involvement in bullying behaviors was associated with a higher risk for depression, SSI, and suicide attempts. Girls who bullied others frequently were at significantly higher risk for depression and suicide attempts than comparable boys. Among boys, 2.5 % were bully-victims, 6.1% were frequently victims only, 10.4% were frequently bullies only, and 28.1% were infrequently bullies or victims. Among girls, nearly 1% were frequently bully-victims, 4.5% were frequently victims only, 4.4% were frequently bullies only, and 22.1% were infrequently bullies or victims. A significantly greater proportion of girls (nearly 70%) than boys (52.8%) were neither bullies nor victims. Boys who were frequently bully-victims were more likely to be depressed and have SSI than boys who were not involved in bullying behavior. Girls who were frequently bully-victims were 32 times more likely to be depressed and 10 to 12 times more likely to have SSI or to attempt suicide compared with girls who were not involved in bullying behavior.

Discussion: Our findings are consistent with reports that bullies, not just victims, are at higher risk of depression, ideation, and attempts (Forero et al., 1999; Kaltiala-Heino et al., 1999; Kaltiala-Heino et al., 2000; Kumpulainen et al., 2000; Roland, 2002; Seals and Young, 2003; Wolke et al., 2001). Moreover, our findings replicate reports that the most disturbed group is the bully-victims (Austin and Joseph, 1996; Juvonen et al., 2003; Kaltiala-Heino et al., 1999; Kim et al., 2005).