Original Investigation | Pediatrics

Association of Recent Violence Encounters With Suicidal Ideation

Among Adolescents With Depression
Jing Wang, MD; Shannon Harrer, MS; Marissa L. Zwald, PhD; Ruth W. Leemis, PhD; Kristin M. Holland, PhD; Deborah M. Stone, ScD;
Kathleen McDavid Harrison, PhD; Elizabeth A. Swedo, MD

Abstract Key Points

Question Among adolescents with
IMPORTANCE Suicide prevention is an important component of depression management.
depression diagnoses, are recent
Knowledge about depressed adolescents with increased risk for suicide can inform suicide
violence encounters associated with
prevention efforts.
elevated risk for suicidal ideation?

OBJECTIVE To describe the risk of documented suicidal ideation within a year following a diagnosis Findings In this cohort study of 24 047
of depression and to examine how the risk of documented suicidal ideation differed by recent adolescents with new depression
violence encounter status among adolescents with new depression diagnoses. diagnoses, more than a quarter (27.5%)
of adolescents who experienced past-
DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study in clinical settings including year violence encounters documented
outpatient facilities, emergency departments, and hospitals. Using IBM’s Explorys database suicidal ideation within 1 year. Recent
containing electronic health records from 26 US health care networks, this study observed a cohort violence encounters were associated
of adolescents with new depression diagnoses from 2017 to 2018 for up to 1 year. Data were analyzed with 1.7 times higher risk for
from July 2020 to July 2021. documented suicidal ideation among
adolescents with depression.
EXPOSURES Recent violence encounter was defined by a diagnosis of child maltreatment (physical,
Meaning These findings suggest that to
sexual, or psychological abuse or neglect) or physical assault within 1 year before depression
prevent suicide, it may be important to
diagnosis.
consider recent violence encounters
when managing adolescent depression.
MAIN OUTCOMES AND MEASURES The main outcome was diagnosis of suicidal ideation within 1
year following depression diagnosis. Multivariable adjusted risk ratios of suicidal ideation were
calculated for overall recent violence encounters and for individual forms of violence. + Supplemental content
Author affiliations and article information are
RESULTS Among a total of 24 047 adolescents with depression, 16 106 (67.0%) were female and listed at the end of this article.

13 437 (55.9%) were White. A total of 378 had experienceda violence (hereafter, encounter group)
and 23 669 had not (hereafter, nonencounter group). Following the diagnosis of depression, 104
adolescents with any past-year violence encounter (27.5%) documented suicidal ideation within 1
year. In contrast, 3185 adolescents in the nonencounter group (13.5%) experienced thoughts of
suicide following the diagnosis of depression. In multivariable analyses, those with any violence
encounter had 1.7 times (95% CI 1.4–2.0) higher risk of documented suicidal ideation compared with
those in the nonencounter group (P < .001). Among different forms of violence, sexual abuse (risk
ratio, 2.1; 95% CI, 1.6–2.8) and physical assault (risk ratio, 1.7; 95% CI, 1.3–2.2) were associated with
significantly increased risk of suicidal ideation.

CONCLUSIONS AND RELEVANCE Among adolescents with depression, persons who experienced
past-year violence encounters showed a higher rate of suicidal ideation than those who had not.
These findings highlight the importance of identifying and accounting for past violence encounters

(continued)

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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Abstract (continued)

when treating adolescents with depression to reduce risk of suicide. Public health approaches to
prevent violence may help to avert morbidity associated with depression and suicidal ideation.

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Introduction
In 2019, as many as 1 in 6 adolescents in the US reported experiencing major depressive disorder
during the past year.1 Depression is the most common mental health condition precipitating suicide,2
making it a crucial target for suicide prevention among adolescents.3 Fortunately, most adolescents
with depression do not have suicidal ideation or behaviors.4 Improved knowledge on distinct groups
at increased risk for suicide among adolescents with depression could facilitate effective suicide
prevention.
Violence encounters are a well-recognized risk factor for suicidal ideation or behavior among
the general youth population.5-8 The link between violence and suicide is theorized to be mediated,
in part, through depression6 but has seldom been studied among adolescents with depression. It is
unclear whether violence encounters elevate risk for suicidal ideation or behavior among those with
depression. Fergusson et al4 showed that sexual abuse during childhood increased the risk for
suicidal ideation or behavior among youth with depression. Their findings underscored that violence
encounters as an adverse childhood experience have deleterious effects on mental health and
well-being9,10 and may increase vulnerability to suicide in later years. Moreover, violence encounters
can have immediate psychological and behavioral sequelae and may affect suicide risk in the short
term.11 Recent exposure to adversity has been found to have particularly strong negative effects on
adolescents’ physical health when compared with adverse experiences during younger childhood.12
As such, particular emphasis should be given to studying recent violence encounters and suicidal
behavior. Foodward et al13 reported that recent assault was associated with suicide attempts among
adolescents with depression in a primary care setting; however, this cross-sectional study could not
define the chronological sequence of being assaulted and suicide attempt. To our knowledge, there
have been no longitudinal studies examining the impact of recent violence encounters and the risk
of suicidal ideation or behavior among adolescents with depression.
Using the IBM Explorys Electronic Health Record database, we conducted a retrospective
cohort study of adolescents with a new diagnosis of depression during 2017 to 2018 with the goals
to: (1) describe short-term risk of documented suicidal ideation at the time of depression diagnosis;
and (2) examine the association of recent violence encounters (ie, child maltreatment and physical
assault) with short-term risk of suicidal ideation. We focused on the time when depression was
diagnosed, as this clinical encounter represents both a high-risk time for suicidal ideation or
behavior14 and a window of opportunity for suicide risk assessment and management among
adolescents with depression.

Methods
Data Source
Explorys data from 2016 to 2019 were analyzed in this retrospective cohort study. Explorys15 is a
longitudinal patient-level electronic health record database covering 15% of the US population and
spanning 50 states. It integrates clinical medical records and claims data for more than 64 million
patients in 26 leading health care networks covering 920 000 practitioners. We used International
Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for all
diagnoses, Systematized Nomenclature of Medicine codes, and Logical Observation Identifiers
Names and Codes to define the clinical conditions as presented in eTable 1 in Supplement 1. Because

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this study was a secondary analysis of deidentified data, the US Centers for Disease Control and
Prevention determined that institutional review board review and the need for informed consent
were exempt. This report follows the Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) reporting guideline for cohort studies.16

Study Population
Two nonoverlapping cohorts of adolescents aged 10 to 19 years were created to increase sample size,
namely the 2017 cohort and the 2018 cohort. The study period for the 2017 cohort took place from
January 1, 2016, through December 31, 2018. This cohort comprised adolescents with a new ICD-10
CM diagnosis of depression in 2017, defined as patients without any past-year documented diagnosis
of depression or antidepressant prescriptions. The date of diagnosis of depression is referred to as
the index date. The study population was limited to adolescents who continuously enrolled in
Explorys during the study period, defined as having at least 1 encounter for any reason in each year
of 2016 to 2018. Following a similar process, a 2018 cohort comprised adolescents with a new
diagnosis of depression in 2018 who continuously enrolled during January 1, 2017, through December
31, 2019 (eFigure in Supplement 1).

Exposure
Our exposure was defined by ICD-10-CM diagnosis of violence encounter occurring within 1 year
before the index date (this group of patients will be referred to as the encounter group hereafter).
Specifically, we included child maltreatment (physical, sexual, or emotional abuse or neglect by a
parent or other caregiver) and physical assault (injuries inflicted by someone other than the parent
or caregiver with the intent to injure or kill). We studied exposure to any violence as well as exposure
to each form of violence. If more than 1 act of violence was documented, we used the most recent
act recorded before the index date. Patients without a diagnosis of past-year violence encounter
(hereafter referred to as the nonencounter group) served as the comparison group.

Outcome
This study focused on suicidal ideation because suicide attempts and death by suicide were
suppressed in the Explorys data set. However, suicidal ideation is an important factor associated with
risk for suicide and suicide attempts. About one-third of adolescents experiencing suicidal ideation
will attempt suicide before adulthood. Among individuals who attempted suicide, most (86%)
occurred within a year of having suicidal ideation,17 highlighting the importance of examining suicide
ideation. The study outcome was defined as an ICD-10-CM diagnosis of suicidal ideation within 1 year
of the index depression diagnosis, which measured short-term suicidal risk that can be especially
pertinent to planning for patient care during their clinical encounters.

Covariates
We classified patients’ characteristics at the time of depression diagnosis into the following
categories: age group (10–14 years, 15–19 years), sex (male or female according to biological sex), race
and ethnicity (Black, Hispanic, White, or other/missing [other race and ethnicity includes American
Indian or Alaskan Native, Asian, Native Hawaiian or Other Pacific Islander, or multiracial]), and
insurance type (public, private, or other/missing). Because either race or ethnicity, but not both, are
often listed in Explorys, when Hispanic ethnicity was specified, it took precedence over race.
‘Missing’ was combined with ‘other’ for the race and ethnicity and insurance variables in statistical
modeling due to small numbers in some violence encounter categories. Race and ethnicity were
analyzed as a covariate because it may be a confounder for the association of violence encounters
and suicidal ideation.
Preexisting substance use was defined as documentation of alcohol use, tobacco use, or other
substance use at any time before the index date. Alcohol use and smoking status were identified
according to patient self-reported behavior or clinician-based ICD-10-CM diagnosis. ICD-10-CM

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diagnoses were used to identify other substance use. As substance use may be a sequela of violence
encounters11—and thus is regarded as a mediator—substance use documented after the most recent
violence encounter was not included as a covariate for the encounter group to avoid overadjusting
for the effects of substance use.
Mental illness was defined as any diagnosis of autism spectrum disorder, attention-deficit/
hyperactivity disorder, conduct disorder, or schizophrenia before the index date and was treated as
confounders associated with violence encounters18 and suicidal ideation.19,20 Anxiety, often a
sequela of violence encounters,11 was considered a mediator and therefore was not adjusted for in
the model. Detailed algorithms to define all conditions are presented in eTable 1 in Supplement 1. The
specified timings relative to the index date in the definitions of each condition are summarized in
eTable 2 in Supplement 1.

Statistical Analyses
Main Analysis
From an initial population of 482 715 patients with a new diagnosis of depression, we excluded
patients who were ineligible to participate because they did not enroll for the entire 3-year study
period (238 143 patients) or were beyond the age range of 10 to 19 years (219 494 patients). To focus
on adolescents with depression as the study population, patients who had a diagnosis of suicidal
ideation before the index date were excluded because they might not have depression when having
suicidal ideation (795 patients). Lastly, to study recent violence encounters, patients whose latest
violence encounter was more than 1 year before the index date were excluded (236 patients).
Statistical analyses were conducted in R version 3.5.1 (R Project for Statistical Computing). We
computed adjusted risk ratios (RR) of suicidal ideation for those with violence encounters compared
with those with no encounters according to multivariable Poisson regression using robust standard
errors.21 In separate models, we obtained RRs for overall violence encounters, as well as for each
form of violence encounter relative to no encounters. We did not estimate RR for child neglect due
to the small sample size (6 participants). Age, sex, race and ethnicity, and insurance type, in addition
to history of substance use and mental illness were used for adjustment in the model. A 2-sided
P < .05 was considered significant. Data were analyzed from July 2020 to July 2021.

Validation Analyses
Given that this study was based on diagnosed cases, we conducted post hoc validation analyses to
evaluate potential sources of bias. Regarding potential detection bias on the outcome, we assessed
whether the encounter group were more likely to be screened for suicidal ideation than the
nonencounter group. We compared the percentage of adolescents receiving the 9-item Patient
Health Questionnaire (PHQ-9)22 assessment in the month before, or 3 months after, the index date
by violence encounter status. Furthermore, children of racial and ethnic minorities or with nonprivate
insurance are frequently overevaluated for child abuse,23 although mainly on physical abuse among
young children. Adolescents with these socioeconomic characteristics are disproportionally affected
by various early-life adversities that may increase risk for suicide.24,25 Their being overrepresented
in the encounter group due to more detection may mislead the results. Thus, we compared the
distributions of race and ethnicity and insurance type among adolescents with violence encounters
as well as among adolescents with depression in our study vs in national population-based
surveys.26-29 Lastly, to ensure that our findings were not affected by antidepressant treatment that
may be associated with the potential risk of increased suicidal ideation,30 we redefined outcome as
suicidal ideation on the same day instead of within 1 year of depression diagnosis when the patients
had not been treated with antidepressants.

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Results
A total of 24 047 adolescents (16 106 [67.0%] female and 13 437 [55.9%] White) had a new diagnosis
of depression during 2017 and 2018, among whom 1.6% (378 adolescents) had a violence encounter
within the past year (Figure 1). Assault (161 participants [42.6%]) was the most common form of
violence encounter, followed by sexual abuse (93 participants [24.6%]), psychological abuse (72
participants [19.0%]), physical abuse (33 participants [8.7%]), and neglect or other violence (19
participants [5.0%]). Compared with the nonencounter group, the encounter group was more likely
to be younger (age 10–14 years), female, Black or Hispanic, and covered by public insurance. In
addition, the encounter group had a higher percentage of previous substance use and mental illness
compared with the nonencounter group (Table 1).
Overall, 13.7% of adolescents (3289 adolescents) had a diagnosis of suicidal ideation in the year
following depression diagnosis. Among the encounters group, 27.5% (104 adolescents) had
documented suicidal ideation, in contrast to 13.5% (3185 adolescents) in the nonencounter group

Figure 1. Study Cohort Accrual Flowchart

482 715 Adolescents with a new diagnosis of depression

458 668 Excluded

238 143 Did not enroll for the entire 3-y study period
219 494 Not aged 10-19 y
795 With suicidal ideation prior to depression
Study period was 2016 to 2018 for the 2017 cohort and
236 Experienced violence encounter >1 y
before depression 2017 to 2019 for the 2018 cohort. The violence
encounter group was composed of adolescents with a
24 047 Included in final study cohort diagnosis of any violence encounter (child
maltreatment–physical, sexual, or emotional abuse or
neglect) and physical assault within 1 year before the
index date. Otherwise, the adolescent was classified as
378 With violence encounter 23 669 Without violence encounter
nonencounter group.

Table 1. Demographic Characteristics for the Study Population by Violence Encounter Statusa

No. (%)
Nonencounter group Encounter group
Characteristic (N = 23 669) (N = 378) P valueb
Suicidal ideation 3185 (13.5) 104 (27.5) <.001
Age group, yc Abbreviation: PHQ-9, Patient Health Questionnaire
assessment.
10-14 6972 (29.5) 134 (35.4)
.01 a
Data source: IBM Explorys Electronic Health Record
15-19 16 697 (70.5) 244 (64.6)
Database.
Sex
b
The distributions in demographic characteristics
Female 15 826 (66.9) 280 (74.1)
were compared between the encounter group and
Male 7760 (32.8) 98 (25.9) .008 nonencounter group according to χ2 test.
Missing 83 (0.4) 0 c
Missing data are not reported for these variables.
Race and ethnicity Because the study population was specified for
Black 2273 (9.6) 81 (21.4) adolescents aged 10-19 years, there was no missing
Hispanic 1648 (7.0) 44 (11.6) value for age group. For substance use and mental
<.001 illness that were identified by ICD-10-CM diagnosis
White 13 242 (55.9) 195 (51.6)
d,e
codes, the records in absence of the specified codes
Other 6506 (27.5) 58 (15.3)
were defined as “no.” Records without indicating
Type of health insurance “PHQ-9 assessment” were treated as “no.”
Private plan 12 811 (54.1) 128 (33.9) d
Other race and ethnicity includes American Indian or
Public plan 5372 (22.7) 144 (38.1) <.001 Alaskan Native, Asian, Native Hawaiian or Other
Othere 5486 (23.2) 106 (28.0) Pacific Islander, or multiracial.
e
Substance usec 2378 (10.0) 71 (18.8) <.001 The category of “missing” was combined with “other”
Mental illness c
5203 (22.0) 100 (26.5) .04 for the race and ethnicity and health insurance
variables in statistical modeling due to small numbers
PHQ-9 assessmentc 2669 (11.3) 45 (11.9) .76
in some violence encounter categories.

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(χ 12 = 62.3; P < .001). Regarding timing of suicidal ideation, the initial documented suicidal ideation
was most commonly identified simultaneously at the time of depression diagnosis (16.7% and 8.9%
of patients from the violence encounter group and nonencounter group, respectively), accounting
for about 61% and 66% of total cases with suicidal ideation in each group. (Figure 2).
After adjusting for covariates, among adolescents with depression, the encounter group had 1.7
(95% CI, 1.4-2.0) times the risk of suicidal ideation compared with the nonencounter group (Table 2).
Regarding specific forms of violence encounters, recent sexual abuse (RR, 2.1; 95% CI, 1.6-2.8) or
assault (RR, 1.7; 95%, CI 1.3-2.2) were found to be significantly associated with increased risk of

Figure 2. The Timing of Initial Documented Suicidal Ideation Following Depression Diagnosis

18
Without violence encounter
16
With violence encounter
14 Data source: IBM Explorys Electronic Health Record
12 Database. The percentage was calculated as number of
Adolescents, %

adolescents (aged 10-19 years) with documented

10
suicidal ideation during each time frame divided by the
8 total number of adolescents for the encounter group
6 and the nonencounter group, respectively. The
months since depression diagnosis date was calculated
4
using the following values: the month value of 0
2 indicates documented suicidal ideation and depression
0 on the same day; the value of 1 or greater indicates
0 1 2 3 4 5 6 7 8 9 10 11 12 13 documented suicidal ideation within the number of
Time since depression diagnosis, mo months after depression diagnosis.

Table 2. Adjusted Risk Ratio for Suicidal Ideation Associated With Violence Encounters Among Adolescents
With Depressiona,b

Characteristic Adjusted risk ratio (95% CI) P value

Violence encounterc
No 1 [Reference]
Yes 1.7 (1.4-2.0) <.001
Violence formc
No encounters 1 [Reference]
Physical abuse 1.4 (0.7-2.7) .36
Sexual abuse 2.1 (1.6-2.8) <.001
Psychological abuse 1.4 (0.9-2.2) .17
Assault 1.7 (1.3-2.2) <.001
Age, y a
Data source: IBM Explorys Electronic Health Record
10-14 1 [Reference] Database.
15-19 0.8 (0.8-0.9) <.001 b
Sex and mental illness were not kept in the final
Race and ethnicity multivariable model as they became nonsignificant
White 1 [Reference] after adjusting for other variables and neither
Black 1.1 (1.0-1.2) .02 significantly changed the coefficient for violence
encounter status.
Hispanic 1.2 (1.1-1.3) .002
c
In separate models, we obtained risk ratios for overall
Otherd 0.6 (0.5-0.6) <.001
violence encounters as well as for each form of
Insurance
violence encounter (physical abuse, sexual abuse,
Private 1 [Reference] psychological abuse, assault) relative to no
Public 1.4 (1.3-1.5) <.001 encounters and adjusting for covariates. Risk ratio for
Other 0.9 (0.8-1.0) .01 neglect was not estimated due to small sample size
(6 participants).
Substance use
d
No 1 [Reference] Other race and ethnicity includes American Indian or
Alaskan Native, Asian, Native Hawaiian or Other
Yes 1.7 (1.6-1.9) <.001
Pacific Islander, or multiracial.

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suicidal ideation. Adolescents with a history of substance use had 1.7 times the risk (95% CI, 1.6-1.9)
of suicidal ideation compared with those without substance use. In addition, younger age (10-14
years), people of Black race or Hispanic ethnicity, and people with public insurance had a higher risk
of suicidal ideation. Neither history of other mental illness nor sex resulted in significant associations
with suicidal ideation.
For validation analyses, screening rates using the PHQ-9 were similar between adolescents with
violence encounters and those without encounters (Table 1), suggesting a detection bias on suicidal
ideation was not present. Among encounters, the percentage of racial and ethnic minority groups
was slightly lower in our study than in national population-based surveys (eTable 3 in Supplement 1).
Among adolescents with depression, the percentages of racial and ethnic minority groups or
nonprivate insured were comparable in our study as in a national survey, which do not suggest
overrepresentation of children of racial and ethnic minorities or with nonprivate insurance in our
sample (eTable 4 in Supplement 1). When we redefined outcome as suicidal ideation on the same day
of the index date to eliminate potential impact from antidepressant treatment, our conclusions
remained unchanged.

Discussion
To our knowledge, this study is the first longitudinal study to comprehensively examine the
association of recent violence encounters and suicidal ideation among adolescents with depression.
We observed a high rate (27.5%) of documented suicidal ideation within a year of depression
diagnosis among adolescents in the violence encounter group. An estimated 1.4 million children and
youth made violence-related medical visits per year, of whom two thirds are adolescents.31 Our
findings underscore the importance of addressing violence exposure when adolescents make
contact with the health care system to curtail mental illness trajectories and suicide risk.32
Unfortunately, violence exposure frequently goes undetected in health care settings, implying
missing opportunities to provide needed services or therapeutic interventions.33 Currently, there is
no consensus on when or how to conduct clinical screening for traumatic experiences, including
violence encounters.34,35 Further efforts are warranted to develop best practices in identifying
violence encounters to guide appropriate clinical care.
Literature indicates that people with depression who experience interpersonal violence may
differ from those who do not experience interpersonal violence regarding clinical courses of
depression, such as earlier age of onset of disease, more episodes, more comorbidities, and delayed
recovery of depression.36-38 History of violence exposure may also moderate individuals’ responses
to depression treatment: combined psychotherapy and pharmacotherapy was found more effective
at treating depression among adolescents with a history of sexual abuse than other treatment plans,
while all types of treatment showed similarly effective for adolescents without violence
experience.39 Our findings demonstrate that adolescents with depression and recent experiences of
violence have higher risk of suicidal ideation compared with their counterparts without such
encounters. Taken together, these studies consistently highlight the importance of identifying and
accounting for violence encounters in depression management, from assessing suicide risk to
determining a treatment plan.40
The mechanism underlying the excessive risk of suicidal ideation associated with violence
encounters among adolescents with depression is not well understood. However, comorbid
substance use or posttraumatic stress disorder—2 sequelae of violence encounters—are known to
increase risk for suicidal behaviors among patients with depression.41-44 Suffering from violence and
associated injury may also decrease one’s fear of death and increase suicidal ideation.6,45 Lack of
coping skills and cognitive processes following traumatic experiences may also be associated with
risk. Maltreated adolescents can exhibit diminished cognitive processes similar to adolescents with
suicidal ideation (eg, catastrophizing, overgeneralization, black-and-white thinking, and
hopelessness).6,46,47 Beyond individual level factors, social and environmental factors also warrant

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consideration. Family level factors, such as economic stress, impaired parent-child relationship,
parental mental illness and substance use, and community level factors, such as concentrated
poverty, high violence, and poor neighborhood cohesion are all associated with interpersonal
violence.48-50 In these contexts, lacking social supports, connectedness, and interpersonal
difficulties may further exacerbate the risk of suicidal behavior following violence encounters.51 To
address these multilevel factors, comprehensive primary prevention approaches can be effective in
preventing multiple types of violence, including suicidal risk.52-54

Limitations
This study had limitations. All conditions were defined via clinical codes, which underestimates the
total number of cases as many may not seek care or receive a diagnosis, and misclassification might
exist. For example, in our study, 13.7% of adolescents documented suicidal ideation within a year
following depression diagnosis, which is lower than the annual rate for self-reported suicidal ideation
(ranging from 30.0% to 42.0% for adolescents aged 14–21 years with depression).4 Similarly,
compared with 1.6% of adolescents with depression who had past-year violent experience in our
study, self-reported data from the National Survey of Children’s Exposure to Violence indicated a
much higher prevalence of past-year violence among adolescents aged 10 to 17 years (ie, about
40%–46% for physical assault and 17%–21% for maltreatment).55 However, only 1.9% made medical
visits following violence exposure (yet this is still equivalent to 1.4 million children and adolescents),31
which may largely explain the low rate of violence encounters observed in our study. Underreporting
of violence encounters, leading to those with encounters being misclassified as without encounters,
may bias the association of violence encounters with suicidal ideation toward null. Substance use was
also likely underdiagnosed as it may not be disclosed or detected. Inability to fully adjust for
substance use may affect our findings. Reassuringly, a prior community-based study found the
relative risk of exposure to assault for suicide attempts was minimally changed by adjusting for
preexisting substance use.56
With a limited follow-up period, we could not define the chronicity of violence encounters.
Similarly, we were able to identify the status of depression and suicidal ideation according to
diagnoses at a certain point after violence encounters, but those may not be the initial occurrences.
There lacks a complete picture of the sequences of the events. Additionally, we could not account for
family- and community-level factors in the analyses. Therefore, no causal relationships could be
inferred from our study. Given that violence experiences that prompt medical visits are usually
severe,31 it is unclear whether our results apply to general violence exposure. Population-based
studies are warranted to address these limitations. Moreover, if patients received care from
practitioners not participating in Explorys, these diagnoses would not be captured in the data. It is
unclear whether this issue would vary by violence encounter status. As electronic health records
generally have low quality data on race and ethnicity,57 often race or ethnicity alone or neither were
documented in Explorys. We combined ‘missing’ with ‘other’ for race and ethnicity and insurance
type in our analyses, preventing us from making interpretations on this population.

Conclusions
This study suggests that recent violence encounters are associated with elevated risk for
documented suicidal ideation among adolescents with depression. Recognizing recent violence
encounters can provide important information for suicide risk assessment and intervention at the
time of depression diagnosis. Preventing violence from occurring in the first place, and mitigating the
negative impacts when it occurs, has the potential to prevent later excessive morbidity from
depression and suicidal ideation.

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ARTICLE INFORMATION
Accepted for Publication: January 10, 2023.
Published: March 2, 2023. doi:10.1001/jamanetworkopen.2023.1190
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Wang J
et al. JAMA Network Open.
Corresponding Author: Jing Wang, MD, Division of Injury Prevention, National Center for Injury Prevention and
Control, US Centers for Disease Control and Prevention, 4770 Buford Hwy NE, S106-9, Atlanta, GA 30341-3724
(zrr4@cdc.gov).
Author Affiliations: Division of Injury Prevention, National Center for Injury Prevention and Control, US Centers
for Disease Control and Prevention, Atlanta, Georgia (Wang, Stone); Palantir Technologies, Cambridge,
Massachusetts (Harrer); Division of Violence Prevention, National Center for Injury Prevention and Control, US
Centers for Disease Control and Prevention, Atlanta, Georgia (Zwald, Leemis, Holland, McDavid Harrison, Swedo).
Author Contributions: Dr Wang had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Wang, Harrer, Leemis, Holland, Swedo.
Acquisition, analysis, or interpretation of data: Wang, Harrer, Zwald, Leemis, Holland, Stone, Harrison.
Drafting of the manuscript: Wang, Harrer, Zwald, Leemis, Holland, Swedo.
Critical revision of the manuscript for important intellectual content: Wang, Leemis, Holland, Stone,
Harrison, Swedo.
Statistical analysis: Wang, Harrer.
Administrative, technical, or material support: Harrer, Leemis, Holland, Stone, Harrison, Swedo.
Supervision: Holland, Stone, Swedo.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by funding 75D30118P02770 from the US Centers for Disease
Control and Prevention (CDC).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation of the manuscript; and decision to submit the
manuscript for publication. The CDC reviewed and approved this article before submission.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent
the official position of the US Centers for Disease Control and Prevention.
Data Sharing Statement: See Supplement 2.
Additional Contributions: Tracey Foster-Butler, BA, CDC’s National Center for Injury Prevention and Control,
edited the manuscript. She did not receive any compensation beyond her normal salary for this work.

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SUPPLEMENT 1.
eFigure. Study Design of the Cohort
eTable 1. Algorithm Used to Define Conditions Included in the Current Study
eTable 2. Specified Timings Relative to the Index Date in the Definitions of the Main Variables
eTable 3. Distribution of Race and Ethnicity Among Adolescents Who Were Exposed to Violence in National
Population-Based Surveys vs in Explorys
eTable 4. Distribution in Race and Ethnicity and Insurance Type Among Adolescents With Depression in National
Survey on Drug Use and Health (NSDUH) vs in Explorys

SUPPLEMENT 2.
Data Sharing Statement

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