Suicide Risk Assessment in a Modern Asian Adolescent Community: A Cultural-relevant Perspective

: Suicide is a serious social and psychological issue that has a devastating socio-economic impact globally. However, it remains elusive as mental health professionals grapple to formulate effective assessment and intervention strategies. Particularly, there is a dearth of cultural-relevant suicide risk assessment scales as most instruments were developed in Western culture. Even with translation and linguistic equivalence, present suicide risk assessment scales do not encompass culturally salient and relevant psychological constructs. This study adopted a socio-cultural approach to develop a suicide risk assessment with sound psychometric properties and also to capture the cultural-specific symptomatology of suicide as well as depressive Asians


Introduction
Suicide is a significant global public health problem, with nearly one million suicide deaths reported worldwide annually (WHO, 2021), and is the second leading cause of death among adolescents and young adults aged between 15 and 29 years (Fleischmann & De Leo, 2014).A similar study noted that actual suicide attempts have become more prevalent among young people and are the main signals of further suicidal risk (Haynes et al., 2016).While suicide is also a national concern in China (Sun et al., 2017), there is a dearth of culturally-relevant research, particularly in assessment and intervention.
For years, suicide prevention programs have been difficult to formulate as no single risk factor could predict suicide with great accuracy (Franklin et al., 2014).It pertains even to common proposed risk factors such as suicidal ideation, which still could not consistently or independently predict suicide behaviour (Klonsky & May, 2014).Suicide behavior has been included in the classification systems of mental disorders, specifically the Diagnostic and statistical manual of mental disorders (DSM-5), as a psychiatric compilation that requires "further study."A diagnosis of Suicide Behaviour Disorder would require meeting all the following five diagnostic criteria: (1) within the last 24 months, the individual has attempted suicide on at least one instance; (2) the act does not meet criteria for non-suicidal self-injury (NSSI); (3) the diagnosis does not apply to suicidal ideation or preparatory acts; (4) the act was not carried out during a state of delirium or confusion; and (5) The act was motivated by purely political or religious objective.
Notably, this proposed diagnosis entails the importance of the individual's intent in defining suicidal behaviour and the individual's expectation that the sequence or set of actions could potentially lead to their own death.Thus, it also differentiates from another "non-suicidal self-injury."Additionally, Kendler et al. (2009) highlighted potential antecedent risk factors or criteria (i.e., family dynamic, socio-demographic and cultural factors), concurrent criteria

Suicide Risk Assessment
As part of the suicide risk assessment, suicidal ideation, and suicide attempts are two significant factors.Suicidal ideation refers to thoughts and desires to end one's life.This ranges from relatively passive ideation (e.g., contemplating death) to active ideation (e.g., planning and preparing for suicide).Past research in community settings showed that youth typically reported suicidal ideation at a moderate frequency, with intensity ranging between mild to moderate frequency (Miranda, Ortin, Scott, & Shaffer, 2014).A suicide attempt is an action motivated to end one's life (Franklin et al., 2016).A classical three-step theory of suicide asserts the role of pain (psychological or emotional) in understanding suicide (Klonsky & May, 2015).It theorizes that the combination of pain and hopelessness is vital for developing suicide ideation, which a lack of social connectedness would aggravate.This theory construes suicidal ideation and behavior as distinct.Research indicated that frequent, intense, and chronic suicidal ideation is related to subsequent suicide attempts (Miranda et al., 2014;Czyz & King, 2015;Wolff et al., 2018).Due to this intertwined relationship, suicidal intent and suicidal ideation are two main assessment areas in psychometric instruments for suicide risk assessment.
It is essential to review some risk factors pertaining to suicide.Such risk was found to be greater in males than females, similar to the general suicide cases (Hawton & van Heeringen, 2009).Another prominent finding was that the level of increased risk was related to the history of suicide attempts, and more so when there was a family's psychiatric history (Cooper et al., 2005).Further, clinical depression symptoms were salient risk factors, especially for more severe psychopathology, a sense of hopelessness, and suicidal ideation tendencies.Likewise, suicide with co-existing disorders was associated with higher risk, including substance misuse for specific alcohol and drugs, anxiety, and personality disorder (Bachmann, 2018;Holmstrand, Bogren, Mattisson, & Brådvik, 2015;Cavanagh, Carson, Sharpe, & Lawrie, 2003).Notably, suicidal ideation and prevalence increase sharply during the teenage years (Nock, Borges, & Ono, 2012;Nock et al., 2013).Such suicidal ideation persists even after youth's hospitalization (Czyz & King, 2015;Wolff et al., 2018).Over one-third of adolescents who reported suicidal ideation they eventually attempted suicide (Nock et al., 2013).Another research showed that young adults with suicidal ideation are estimated to be 12 times more likely to attempt suicide by the age of 30 (Reinherz, Tanner, Berger, Beardslee, & Fitzmaurice, 2006).It is notable that the majority of teenagers with suicidal ideation would eventually attempt suicide within 1-2 years of such suicidal ideation onset (Glenn et al., 2017), and they are commonly characterized by specific clinical issues, particularly depression or dysthymia (Nock et al., 2013).Other studies have also documented that suicides cases between 9-8 years (e.g., Bridge et al., 2015;Groholt, Ekeberg, Wichstrom, & Haldorsen, 1998) and have become more and more common by 15-19 years (Kolves & de Leo, 2017).These findings pointed out the role of social and emotional processing (i.e., emotional dysregulation) in the development of suicidal thoughts, which could lead to suicide behavior (Gratz et al., 2020).Indeed, the role of suicide intent on eventual suicide is more significant than previous attempts or a sense of hopelessness (Zhang & Norvilitis, 2002).Thus, it has been recommended for the measurement of suicide intent be included in clinical practices for suicide.At the same time, clinical depression appears to be a key precursor to suicide.It is, therefore, essential to elucidate the relationship between major depressive disorder and suicide.Further, such development warrants the urgency and pertinence of developing effective assessment, and intervention.

Asian culture and collectivism
A review of risk factors for young adults' suicidality highlighted that psychiatric or mental disorders coupled with a prognosis of suicidal behavior and suicide are significant predictors of suicide behavior and mortality by suicide (King & Merchant, 2008).It also further argued about the role of social and interpersonal factors in understanding and predicting suicidal behavior.Most research on suicide risk assessment adopts an individualistic and deterministic view of human psychology and behaviour.Nevertheless, Bronfenbrenner's ecological model posited the role of 10.54392/ajir2333 multiple ecological contexts in shaping an individual's well-being, and indeed, evidence has suggested the importance of the biopsychological model in accounting and conceptualizing the dynamic nature of suicide behavior (Brofenbrenner, 1977;Heaney & Israel, 2008).Interpersonal Theory of Suicide (Joiner, 2005;Van Orden et al., 2008) outlined the suicidal risk as a combination of frustration or lack of social connection and a sense of low selfworth and perceived burdensome.This further suggested that suicide entails a relational and social element In this paper, the focus would be on risk assessment in the context of Asian society, particularly in China.This is an area of interest as there has been a high suicide ideation rate and incidences among Chinese in recent years (Zhang et al., 2014).Recently, there is a sharp increase in report cases of depression and suicide in Asian population, particularly in overseas Chinese societies like Singapore, which have seen fast industrial and economic development (Arafat et al., 2022).The quest to assess and prevent suicide have not been effective, particularly among youth and children as they are not proactive or less vocal in reporting their suicidal risk, hence their parents and guardian often overlook the potential risk to their children.Thus, it is essential to adopt a culturally-informed and relevant approach in formulating assessment instruments and in understanding suicide.
Youth face the developmental task of developing their identity through individuation and independence from their family (Erikson, 1959).Such emotional autonomy was found to be related to depressive symptomatology (Chou, 2000).Unlike Westerners, Asians strive for integration instead of individuation.Therefore, social approval and concern over interpersonal relationships would be key areas in influencing depressive symptoms and suicidal risk.In Chinese societies influenced by Confucian Heritage Culture, students face societal pressure to excel academically.Cross-cultural research suggested that Western youth have more interest in pursuing individuation and romantic relationship as compared to Singaporean adolescents (Koh, Koh, & Chang, 2002).The high value in social-oriented achievement such as academic competence and cognitive skills related to academic achievement would be significant in shaping Chinese's mental well-being.Hence, the development of a culturally relevant instrument for mental welling and suicide would take into account the manifestation and phenomenological experiences which are shaped by adolescents' developmental and culture tasks (Kleinman & Good, 1985).
During adolescence, the individual is facing the challenge of developing his unique identity through individuation and becoming independent of his family (Erikson, 1959).Chou (2000) also found that depressive symptomatology was associated with 2 aspects of emotional autonomy, i.e., individuation and de-idealization of parents.In a collectivist Asian society where the emphasis is on integration rather than individuation, we questioned if identity formation would become a challenge to Asian adolescents and lead to depression.On the other hand, since others are of high importance in the self-construct of collectivist Asians, we speculated that concern over selfother relationships might be a critical concomitant of depression for Asian adolescents.Adolescents in Asia, especially in the Confucian Heritage Cultural communities such as Japan, Taiwan, Hong Kong, and Singapore, also face tremendous pressure for academic achievement.A study comparing stress and coping in Singaporean and American adolescents found that academic pressure was the most frequently experienced stressor for Singaporean adolescents, in contrast to American adolescents, who were more concerned over romantic relationships and individuation from parents (Koh, Koh, & Chang, 2002).We, therefore, proposed that concerns over academic competence and the cognitive skills related to academic success or failure might be significant for Singaporean adolescents.Depression is a condition whose manifestations and phenomenological experiences are intimately formed by the culture and the developmental tasks faced by adolescents (Kleinman & Good, 1985).
Having outlined the significance of a cultural-relevant perspective, it is essential to examine how sociocultural influences the manifestation of depression symptoms, behavior, and potential suicidal development.Major depression is a psychological disorder with impairments in cognitive, emotional, and neurobiological domains.Several etiological models indicated that an amalgamation of developmental, psychosocial, neurobiological, and genetic factors leads to Major Depressive Disorder (MDD) (Kendler et al., 2006;Sjoholm et al., 2009).Across cultures, key symptoms of major depression are persistent low mood, a sharp reduction in energy, and interest, intense feelings of worthlessness, hopelessness, and some reported excessive guilt.These symptoms are observed cross-culturally (Sartorius et al., 1980).However, subjective experiences and symptom presentation can vary across cultures (Ying, et al., 2000) and this could pose a challenge in assessing depression in non-western cultural groups (e.g., Iwata, N., & Buka, 2002).It is postulated that the relationship between culture and depression is mediated by individual's selfconstrual (Markus & Kitayama, 1991).The collectivistic nature of Chinese communities entails relatively more 10.54392/ajir2333interdependent self-construal (Triandis, 1989) and their "idiom of distress" were found to contain more symptoms regarding social aspects of the self (Esau & Chang, 2009;Chang, 1985).In such culture, social contexts are deemed as an integrative part of self-construct (Triandis, 1989).Indeed, the values and belief systems of a culture influence individuals' goals and motivational efforts (Markus & Kitayama, 1991).Thus, their psychological state would be influenced by interpersonal and social processes.For instance, the perception of a lack of parental support and peer acceptance (i.e., interpersonal factors) are found to be predictive of depressive mood among Hong Kong Chinese adolescents ((Stewart et al., 1999).So, it is meaningful to incorporate interpersonal elements of depression as these are culturally sensitive and relevant to depressive symptomatology.However, these constructs are often absent in most assessments developed in the West.
Other socio-cultural research found that Asian tend to place less emphasis on affective symptoms; instead, they tend to present somatized complaints (Stein, 1990).Chang (1985) found that Asian Americans demonstrated higher salience for psychosomatic symptoms as compared to ethnic Americans.Likewise, East Asian and Asian American reported similar psychosomatic depressive symptoms but less affective or emotional symptoms.Other relevant sociocultural research suggested that guilt and shame appear to influence Chinese suicidal tendencies.Several scholars have begun to highlight the salience of shame among Asian Americans due to its presence in several Asian languages and parenting techniques (e.g., discussing children's transgressions in front of others to induce shame and socialize children to behave properly; Louie, 2014), and higher levels of shame experiences compared to Caucasians (as cited in Wong et al., 2014).The collectivistic nature of Asian also influences their high need for social approval and desire to fulfill socially prescribed duties, hence leading to a sense of shame when they are unable to meet social expectation (Lutwak, Razzino, & Ferrari, 1998).Wong et al. (2014) conceptualized shame as an interpersonal experience, which comprises two dimensions: (1) external shame (i.e., concerns about negative social perception toward self), and (2) family shame (i.e., concerns about bringing shame to one's family).Research showed that external and family shame was positively correlated with depression and suicidal ideation but negatively correlated with self-esteem (Wong et al., 2014).Self-conscious moral emotions such as guilt and shame (Tangney, 2002) have been found to be particularly salient during Major Depressive Disorder (Zahn et al., 2012).Meta-analysis studies showed that those who reported high levels of shame were less effective in communicating their suicidal intent and often could not be understood when they seek help through indirect means (Pompili et al., 2016).Studies in community settings and college students showed that shame was positively associated with suicide ideation (Zhao et al., 2020).Similarly, excessive, persistent, and inappropriate sense of guilt is considered as a clinical symptom of MDD, particularly for melancholic subtype (American Psychiatric Association, 2000).A recent meta-analysis showed that younger adults with current major depression reported higher levels of guilt as compared to older adults (Hegeman et al., 2012).Another research indicated that a sense of guilt was characterized by female MDD patients who had a history of suicide attempts (Bi et al., 2012).Past research also revealed that patients with current MDD reported significantly high levels of guilt (Berrios et al., 1992).

Development of a Cultural-Relevant Assessment
It is important to review the current suicide risk assessment scales in past research.Baek et al. ( 2021) noted that self-reporting is the common method to identify symptoms related to suicide risk.This is a common approach to screening suicide risk groups, and interviews would be carried out to assess the severity of suicidal ideation.Such structured interview tool aims to minimize the subjectivity of experts' judgment.Other researchers have investigated the factors predictive of suicidal behavior and found that major depression, impulsiveness, life events, and sociodemographic factors (Twenge et al., 2019).Thus, it is essential to include major depressive disorder, particularly culturally relevant factors, in the development of suicide assessment instruments.Indeed, there is a lack of consensus over diagnostic criteria, an absence of culturally appropriate norms, and a dearth of cultural validity in the assessment (Chang & Koh, 2012).Recent research examined the validity and reliability of a Chinese language suicide screening questionnaire-observer rating (CL-SSQ-OR) assessment for children and youth (Yu et al., 2023).However, this research largely considered the linguistic equivalence of assessment scale items in Chinese culture and did not integrate socio-cultural relevant constructs such as major depressive symptoms, interpersonal and psychosomatic constructs which had been found to be a precursor to suicide, and predictive of suicide.Perhaps such inclusion would bolster the diagnostic capacity and improve the preventative effort as it reflects a shared Asian cultural emphasis.The aim of this theoretical paper is to develop a cultural-relevant suicide assessment scale with sound psychometric properties and incremental validity over previous instruments developed in the West.Incremental validity refers to the extent a scale confers predictive validity over existing scales (Haynes & Lench, 2003).Kate et al. (2000) and other research typically included Beck's inventory of depression and hopelessness with suicide risk assessment.We argue that this might not be appropriate as these did not sufficiently consider the cultural experience and values of Asians, such as concern over interpersonal relationships, psychosomatic manifestation, emphasis on socially approved success such as achievement, and developmental concern for social integration instead of individuation.Other research which attempted to adopt Western Scales in the past was mainly concerned with linguistic equivalence and translational issues but failed to take into account salient cultural-sensitive and relevant nuances, which would no doubt affect the effectiveness of the assessment.

Measures
The first part of the questionnaire would encompass the Chinese Suicide Intent Scale (SIS), which has been validated in Chinese society (Gau et al., 2009).The study adapted and extracted 7 statement groups each assessing various aspects of suicidal ideation.Each statement group consists of three sentences that describe different intensities of suicidal ideation, representing a three-point scale (0 to 2).The prospects are instructed to select the specific statement of each group that is most applicable to them with higher values indicating a greater risk of suicide.We do not distinguish different degrees of suicidal risk nor set a cut-off criterion as even very low total scores can be associated with significant risks of suicide.These items would serve as a screening instrument for suicidal ideation.This scale would cover three factors: (1) precautions (four items; e.g., isolation, timing and precautions against discovery); (2) planning (three items; e.g., degree of planning, writing a note and final acts); and (3) seriousness (eight items; e.g., the purpose of attempt, seriousness, expectation regarding fatality) for high variance, and such high construct validity would provide the support that C-SIS has sound psychometric properties.Thus, it is a qualified and appropriate measure for assessing suicidal behavior in the Chinese population.Unlike the previous studies done by Gau et al. (2009) and Zhang and Jia (2007), this study did not draw depressive symptoms items from Beck Depression Inventory.Instead, the study would include salient cultural factors from Singapore Depression Scale (Chang & Koh, 2012) and the Asian Adolescent Depression Scale (Woo et al., 2007).
For the Asian Depression Scale, this author has drawn two socio-psychological constructs as follows: (1) Loss of Meaning of Life (five items; e.g., "I feel hopeless and I feel that my life is empty"); and (2) Affective-Somatic Symptoms (seven items; e.g., "My heart beats faster than normal and I have crying spells").
From the Asian Adolescent Depression scale, this author has also drawn the following: (1) Cognitive Inefficiency (four items: e.g., "I cannot think well and I cannot concentrate on my studies as much as I used to"); (2) Negative Self-evaluation (twenty items; e.g., "I feel that I am not as good as others and I feel that I am not wanted").Chang and Koh (2007)'s assessment of the psychometric properties showed that these constructs provide a more accurate assessment and more effectively capture the cultural experience of Asians (Koh et al., 2002).Participants are asked to rate each item on the extent to which they generally feel on a five-point scale (1=very slightly or not at all; 5=extremely), with higher values indicating a higher level of depressive symptoms.
In this study, the Asian Suicide Risk Assessment comprises items from the Chinese Suicide Intent Scale and Asian Depression Scale, which fulfill the author's quest to develop a cultural-relevant questionnaire for his suicide risk assessment.Both scale items have been validated within the Asian and Chinese cultural settings and showed sound psychometric properties for assessment purposes.As reiterated, suicide and depression are sociopsychological phenomena that manifest within a culture.Beyond only striving for translation accuracy and linguistic equivalence, this study bolsters the clinical utility by incorporating culturally-specific and relevant constructs, particularly: 10.54392/ajir2333

II. Asian Depression Symptoms
Instruction: This section assesses depressive symptoms in adolescents, and higher scores in respective depressive categories indicate the severity of the depressive-suicidal risk.
Scoring Scheme: Participants are asked to rate each item on the extent to which they generally feel on a 5point Likert rating scale (1=very slightly or not at all; 5=extremely).The maximum score is 90 with a cutoff score at 45.The higher the score the more depressive a person is with a higher indication of depressive-suicidal risk.

Conclusion
The study adopted a cultural-relevant approach to developing an Asian Suicide Risk Assessment instrument.It considers the role of socio-cultural influence in shaping the manifestation and development of suicidal and depressive symptoms.By drawing from instruments that have been validated within Asian culture, this study aims to formulate a culturally relevant scale that appropriately captures the cultural nuances, thereby exhibiting greater clinical utility and incremental validity over present instruments.Generally speaking, Asians are less expressive and often take a more collectivistic stand, this author proposed and included culturally salient factors such as affectivesomatic symptoms, and interpersonal and social-oriented evaluation, which were previously lacking in previous suicide risk assessment items.In addition, it included a developmentally salient factor (i.e., cognitive efficacy) that aptly characterizes young Asians' industrious nature and emphasis on achievement in career and academics.With these, the authors believe that it would be a versatile instrument to test for suicidal-depressive risks within Asian culture. .