Key Points

Question Is parent religiosity associated with a lower risk for suicidal ideation/attempts in their offspring?

Findings In a multigenerational longitudinal observational study (112 parents and 214 offspring), parent belief in the high importance of religion was associated with an approximately 80% decrease in risk in suicidal ideation/attempts in their offspring compared with parents who reported religion as unimportant. The association of parental belief was independent of the offspring’s own belief in the importance of religion and other parental risk factors and was statistically significant.

Meaning Among various risk factors for suicidal behavior in offspring, parental religious beliefs should not be overlooked.

Abstract

Importance Previous studies have shown an inverse association between offspring religiosity and suicidal ideation/attempts, but the association of parent religiosity on offspring suicidal ideation/attempts has not been examined.

Objective To examine associations of parent and offspring religiosity with suicide ideation and attempts in offspring.

Design, Setting, and Participants The study is based on offspring (generation 3) from a 3-generation family study at New York State Psychiatric Institute and Columbia University, in which generations 2 and 3 were defined as being at high risk or low risk for major depressive disorder because of the presence or absence of major depressive disorder in generation 1. The association between suicidal behaviors (ideation/attempts) and parent and offspring religiosity in generation 3 offspring aged 6 to 18 years (214 offspring from 112 nuclear families) was examined.

Main Outcomes and Measures Parents’ psychiatric diagnoses and suicidal behaviors were assessed with the Schedule for Affective Disorders and Schizophrenia, and offspring were independently assessed using the child version. Two measures of religiosity were assessed: religious importance and religious attendance. Logistic regressions in the framework of generalized estimation equations were performed to analyze offspring suicidal behaviors while adjusting for sibling correlation and offspring age, sex, and familial depression risk status.

Results Of 214 offspring, 112 (52.3%) were girls. Offspring religious importance was associated with a lower risk for suicidal behavior in girls (odds ratio [OR], 0.48; 95% CI, 0.33-0.70) but not in boys (OR, 1.15; 95% CI, 0.74-1.80) (religiosity by sex interaction, P = .05). Religious attendance was associated with a lower risk for suicidal behavior in girls (OR, 0.64; 95% CI, 0.49-0.84) but not boys (OR, 0.94; 95% CI, 0.69-1.27) (religiosity by sex interaction, P = .17). Parent religious importance was associated with a lower risk for offspring suicidal behavior (OR, 0.61; 95% CI, 0.41-0.91) but not parent religious attendance. When parent and offspring religious importance were considered simultaneously, we found a lower risk associated with parental religious importance (OR, 0.61; 95% CI, 0.39-0.96) independent of offspring importance. These associations were independent of parental depression, marital status, and parental suicide ideation.

Conclusions and Relevance In this study, parental belief in religious importance was associated with lower risk for suicidal behavior in offspring independent of an offspring’s own belief about religious importance and other known parental factors, such as parental depression, suicidal behavior, and divorce.

Introduction

Suicide is the primary cause of death among females aged 15 to 19 years.1 In the United States, approximately 12% of adolescents report having thoughts about attempting suicide, and 4% have made a nonfatal suicide attempt.2 Previous research has examined a number of risk factors of child and adolescent suicide, but one that has received little attention is religious/spiritual belief. This is surprising given that religious beliefs and practices have been associated with lower rates of suicide since Durkheim’s seminal work more than 100 years ago3 and that there have been numerous studies of the association between religiosity and suicide in adults.4-10

The few studies that have examined the association between child/adolescent religiosity and suicidal behaviors have generally shown that religious attendance and belief in the importance of religion are associated with decreased rates of suicide ideation and attempts.11-13 Moreover, this association tends to only be observed in girls.11-15

While the role of offspring’s own religiosity on their suicidal behavior has been limited, there have been no studies examining the contribution of a parent’s own religiosity to an offspring’s suicidal behavior, to our knowledge. Prior studies have demonstrated positive associations of parent religiosity on children’s physical and mental outcomes.16-19 They have also found that the effect of a parent’s religiosity may vary by the sex of an offspring and that congruence in parent/offspring religiosity is also important.20

Drawing on a sample of multiple generations of families at high and low risk for depression, our objective was 3-fold: (1) to attempt to replicate in this sample the association between the offspring’s own religiosity and offspring’s suicidal behavior, (2) to examine the association between parents’ religiosity and offspring suicidal behavior, and (3) to examine the simultaneous association of parent and offspring religiosity on offspring’s suicidal behavior. Additionally, we wanted to examine these associations, if any, in the presence of other well-established associations with suicidal ideation/attempts (SI/A) in parents and offspring.

Using data from a 30-year sample of children and adolescents whose parents were at high or low risk for major depressive disorder (MDD) by virtue of their grandparents’ depression status,21,22 we examined the associations between offspring suicidal behaviors and both parents and offspring religiosity, as assessed by personal belief in the importance of religion and the frequency of religious service attendance after adjusting for other parental factors, such as parental lifetime depression, parental lifetime suicidal ideation, and parental marital status. The design of our study also allowed us to examine the differential associations of parental religiosity by sex of parent, as well as sex of offspring.

Method

Study Design

The data are from an ongoing 3-generation study of families followed up for 30 years.21,22 In brief, the first generation (G1; the probands) included adults with no history of depression (low risk) or who were clinically identified as having a history of MDD (high risk). Their biological offspring comprised the second generation (G2), and their grandchildren comprised the third (G3). G2 and G3 participants were invited to participate in the study when they became age-eligible (ie, 6 years or older). As such, the design of this study does not conform to a conventional longitudinal design as participants’ entry into the study was staggered. High risk of depression in G2 and G3 participants was based on the lifetime diagnoses of MDD of G1. Participants were assessed at baseline and at 2, 10, 20, 25, and 30 years later (T0, T1, T10, T20, T25, and T30, respectively). Assessments of religiosity were conducted at every wave starting at T10. The current analyses were restricted to grandchildren (G3) of the original probands who were between ages 6 and 18 years inclusive during at least 1 assessment and also had a religiosity assessment during the same time together with their parents (G2), who were the biological offspring of the original probands.1 One hundred and ten grandchildren had only 1 assessment, while 104 had at least 2 assessments while they were still age-eligible (ie, between ages 6 and 18 years). All interviews were approved by the institutional review board at New York State Psychiatric Institute/Columbia University. Written informed consent was obtained from adults for themselves and minors; verbal assent was obtained from minors.

Participants

Overall, 214 G3 individuals aged 6 to 18 years (inclusive) had data on SI/A and religiosity at T10, T20, T25, or T30. When a member of G3 was between ages 6 and 18 years during more than 1 time interval, if the G3 participant reported having SI/A at more than 1 wave, the last SI/A observation was used, along with the religiosity observation reported in the same time as the SI/A report. If a G3 participant did not report having SI/A during ages 6 to 18 years, the last recorded observation for religiosity data was used. Thirty-nine offspring had SI/A between the ages of 6 and 18 years (mean [SD] age, 12.3 [3.5] years; median, 13 years), and 175 offspring did not report SI/A between the ages of 6 and 18 years (mean [SD] age, 12.6 [3.5] years; median, 13 years).

The 214 offspring were from 112 distinct families. Thus, 112 G2 parents (ie, the biological offspring of G1 and either the biological mother or father of G3) were included, 1 from each family. Parents who were spouses of the G2 parents were not included in this study because of the large number of spouses who were not biological parents with missing data. The religiosity data for the parents were matched to the same time interval selected for their offspring. For example, if the last religiosity observation of the offspring came from T30, then the parent’s religiosity data were also selected from T30.

Assessments

The Schedule for Affective Disorders and Schizophrenia–Lifetime Version23 for adults and the child version24 modified for DSM-IV for children and adolescents aged 6 to 17 years across all waves provided the diagnostic suicidal data. The assessments were administered by trained doctoral and master’s level mental health professionals masked to the clinical status of the parents and other generations. Final best estimate diagnoses25 were made by experienced psychiatrists or PhD psychologists not involved in the interviewing and masked to the clinical status of previous generations.

Religious service attendance was determined by responses to the question: How often, if at all, do you attend church, synagogue, or other religious or spiritual services? (Once a week or more, about once a month, about once or twice a year, less than once a year, never.) Religious importance was measured by responses to the question: How important to you is religion or spirituality? (Highly important, moderately important, slightly important, not at all important.)

Statistical Analyses

Group comparisons between demographic and clinical variables were conducted using t tests for continuous and χ2 or Fisher exact tests for categorical variables. The associations between G3 SI/A and each religiosity variable for offspring and parents were examined by a series of logistic regressions, with G3 SI/A as the dichotomous outcome and offspring/parent importance/attendance as predictors (individually in univariate regression, then parent and offspring religiosity variables together in multivariate regression) to determine whether each of the religiosity variables individually predicted the occurrence of offspring SI/A between the ages of 6 to 18 years, as well as the simultaneous associations of parent/offspring religiosity. Both religiosity variables were treated as continuous variables; as such, the odds ratios (ORs) associated with these variables represent the increase or decrease in odds relative to the adjacent level of importance/attendance. These regression analyses were carried out in a generalized estimation equation framework to adjust for possible correlation of outcomes between G3 siblings; all analyses were adjusted for age, and offspring sex was adjusted for when investigating the entire sample. In addition, a binary variable representing high-risk or low-risk status was included in all analyses to reflect the design of the study. To investigate potentially confounding associations of well-established factors on the association between parental religiosity variables and offspring SI/A, we included these factors (ie, parental MDD, SI/A, and marital status) as independent variables in the regression analyses modeling the association between parent and offspring religiosity variables and SI/A in the offspring. Differences in association with offspring’s sex were explored by stratifying the sample by sex and fitting separate models to each stratum, in addition to including religiosity by sex interaction terms in models fitted to the overall sample.

Results

Sample Characteristics

Table 1 summarizes the demographic and clinical variables and responses to the 3 religiosity items for 214 offspring and their 112 parents. The mean (SD) offspring age was 12.5 (3.5) years, and the mean (SD) parental age was 39.8 (5.3) years. There were no significant differences in offspring sex, although there was a slightly higher proportion of girls (112 [53%]). The annual median income of parents was $40 000, and 53 parents (47%) were high school graduates. Approximately 80% of parents were married or remarried (n = 87). No significant differences were found in importance of religion in either offspring or parents by their sex. Similarly, attendance at religious services did not differ by offspring or parent sex.

A total of 182 (85%) offspring reported that they belonged to a Christian religious denomination, with 127 (59%) being Catholic and 55 (26%) being Protestant. Approximately two-thirds of the offspring (n = 135) were from the high-risk (vs low-risk) group, but the rates of SI/A did not differ by risk status or by offspring sex. Approximately 18% of parents had lifetime SI/A (n = 20), with rates of suicidal ideation being slightly higher in mothers; there were no differences by risk group.

Associations of Offspring Religiosity

The associations of offspring religious importance and attendance were assessed with separate logistic regressions. The logistic regression results in Table 2 show the associations of offspring religious importance as measured by the OR representing a 1-unit increase in religious importance on SI/A. Table 2 shows the OR based on the entire sample of offspring while controlling for their age, sex, and high-risk and low-risk status; no significant association was found (OR, 0.84; 95% CI, 0.58-1.21; P = .36). The ORs corresponding to the association of offspring religious importance stratified by their sex is also available in Table 2. The OR for girls was less than 1 and was highly significant (OR, 0.48; 95% CI, 0.33-0.70; P < .001), implying a significant reduction in the odds of SI/A in girls with increasing belief in religious importance. There was no statistically significant association of SI/A with religious importance in boys. A formal test of interaction of religious importance by offspring sex found that the association differed significantly by sex (z = −2.00; P = .05).

Similar overall associations were found for religious attendance (Table 2). There was no significant overall association (OR, 0.83; 95% CI, 0.66-1.05; P = .13), a statistically significant association in girls (OR, 0.64; 95% CI, 0.49-0.84; P = .001), and no significant association in boys (OR, 0.94; 95% CI, 0.69-1.27; P = .69). Formal tests for differential associations of religious attendance by offspring sex, however, failed to reach statistical significance (z = −1.36; P = .17).

Associations of Parent Religiosity

Results of similar analyses show the association of parent’s belief in religious importance and parent’s frequency of religious attendance on SI/A in their offspring (Table 2). Higher parental belief in religious importance was associated with lower risk in suicidal behavior on their offspring (OR, 0.61; 95% CI, 0.41-0.91; P = .02); these results imply that there was an approximately 40% decrease in risk of suicidal behavior in offspring for each increasing level of parent’s importance, resulting in an 80% decrease in risk of suicidal behavior in offspring whose parents reported the highest level of importance compared with offspring whose parents reported that religion was not important. Frequency of parent’s religious attendance was not associated with offspring SI/A.

When stratified by offspring sex (Table 2), parents’ religious importance was found to be associated with lower risk in suicidal behavior SI/A in daughters (OR, 0.51; 95% CI, 0.29-0.90; P = .02) but not in in sons (OR, 0.75; 95% CI, 0.47-1.19; P = .22), but this difference was not statistically significant (z = −1.04; P = .30). Similarly, frequency of parents’ religious attendance was found to be associated with lower risk of suicidal behavior in daughters (OR, 0.71; 95% CI, 0.53-0.95; P = .02) but not for sons (OR, 0.89; 95% CI, 0.67-1.19; P = .44), although this difference was not statistically significant (z = −0.88; P = .38).

Exploratory Analysis Stratifying by Pubertal Status of Offspring

To address the issue of key developmental times when parent religiosity has a greater influence in the lives of offspring, we examined the association of parents’ religious importance separately among prepubertal (aged <13 years) and adolescent (aged ≥13 years) offspring (eTable in the Supplement). Our results show that the associations of parental importance on offspring SI/A is statistically significant for adolescents but not significant for prepubertal offspring, although results of formal tests of interaction were not significant and the direction of the association was the same in both groups. In contrast, there was no difference in significance in the association of parental attendance by pubertal status of offspring.

Exploratory Analysis Stratifying by Sex of Parent and Offspring

Stratification by parent sex shows that overall, mothers’ and fathers’ religious importance have a significant association with lower risk of suicidal behavior on SI/A in their offspring (Table 2) (mother’s religious importance: OR, 0.59; 95% CI, 0.34-1.00; P = .05 and father’s religious importance: OR, 0.41; 95% CI, 0.17-0.98; P = .04). Frequency of parents’ religious attendance was not associated with SI/A when stratified by parents’ sex. Further stratification by sex of offspring shows that the association of mothers’ religious importance was observed primarily in girls, but the association of fathers’ religious importance did not appear to vary with sex of offspring.

Simultaneous Associations of Parent and Offspring Religiosity

Religious Importance

Table 2 shows the simultaneous associations of parent and offspring religious importance when included in the same logistic regression analysis. This allows us to determine if there exists an association of parents’ religious importance above and beyond that of the offspring’s religious importance on offspring SI/A. Based on the results of the individual associations of offspring and parent religious importance with offspring SI/A, we first fit a model that included the main associations of parents’ religious importance and offspring’s religious importance, as well as an interaction term between offspring religious importance and offspring’s sex. The association of parent’s religious importance in the overall sample remained unchanged in magnitude (OR, 0.61; 95% CI, 0.39-0.96; P = .03), indicating that its association is independent of offspring religious importance while the main association of offspring’s religious importance remained nonsignificant (OR, 0.98; 95% CI, 0.64-1.50; P = .92); however, the interaction term representing the differential association of offspring religious importance on offspring SI/A was marginally significant (z = −1.91; P = .06). This implies that offspring’s religious importance had a greater association on girls’ SI/A when compared with that of boys. When an interaction term for a parent’s religious importance by offspring’s sex was included in this model, it was found that the interaction term was nonsignificant, suggesting that the magnitude of the association of parent’s religious importance was significantly associated with offspring SI/A but did not differ by offspring sex.

When stratifying by offspring’s sex, we found that for girls, there was a significant association of their own religious importance on their SI/A (OR, 0.60; 95% CI, 0.36-0.98; P = .04). The association of the parent’s religious importance (OR, 0.64; 95% CI, 0.37-1.10; P = .11) on girls’ SI/A was similar in magnitude but did not reach statistical significance. There were no statistically significant associations of either parent (OR, 0.69; 95% CI, 0.39-1.21; P = .20) or offspring religious importance (OR, 1.32; 95% CI, 0.76-2.31; P = .32) on SI/A in boys. These findings need to be interpreted with caution, however, owing to the limited sample sizes of the strata.

Correlation Between Parent and Offspring Religiosity

Results shown in Table 3 can be viewed as a measure of transmission of religiosity between parent and offspring. Correlation between parent and offspring frequency of religious attendance is, in general, greater than that of the correlation between parent and offspring for religious importance. The relatively high correlation between parent’s and daughter’s religiosity may account for the fact that including both offspring and parent religiosity in the logistic regression models simultaneously reduces the associations of both parent and offspring religiosity compared with the analyses in which offspring religiosity and parent religiosity and their association with offspring suicidal ideation were examined separately. There were no associations of either parents’ or offspring’s religious attendance on offspring SI/A in the overall sample or when the sample was stratified by offspring sex.

Associations of Parental Religiosity When Controlling for Parental Depression, Suicidal Ideation, and Marital Status

Parental depression and suicidal ideation are 2 of the strongest risk factors for offspring SI/A.26 Results of including these risk factors in addition to parent’s religiosity, as well as the inclusion of offspring religiosity in these models, can also be seen in Table 4. The results of including parent’s marital status in models that included parent diagnoses and parent religiosity and inclusion of both parent and offspring religiosity in these models are available in Table 5. The findings show that the associations of parental religiosity on offspring suicidal behavior are independent of established risks of parental depression, suicide ideation, and marital status (eResults in the Supplement).

Discussion

We examined independent associations of parents’ and offspring’s religiosity and their interdependence on suicidal ideation and attempts in offspring from families that were at high and low risk for depression by virtue of the grandparents’ depression status. Consistent with the literature, offspring religiosity (religious importance and religious attendance) was significantly inversely associated with suicidal behavior in girls (n = 112) but not boys (n = 102).11-15

Religious importance and religious attendance in a parent were inversely associated with daughters’ suicidal behavior, but only parental religious importance was inversely associated with sons’ suicidal behavior. Exploratory analysis, stratifying by sex of parent in addition to sex of offspring, showed that the association with parent’s religious importance had an association with sons and daughters regardless of parent sex. Parent’s frequent attendance, on the other hand, was found to be a lower risk factor only in mothers and only against suicidal behaviors in daughters. These findings suggest that parent’s belief in the importance of religion may be a more robust factor than a parent’s attendance at religious services and makes one wonder whether religious importance might be more strongly associated with teaching and beliefs about suicide within the home than is service attendance, or whether some other mechanism might be responsible. Our results show that interdependence between parents’ and offspring’s religiosity was considerably stronger for frequency of attendance than for importance of belief, consistent with our own studies of previous generations,20 as well as studies of others17 as reflected in the high correlations found between parents’ and offspring’s religious attendance compared with religious importance.

When we examined some of the strongest risk factors that have been previously cited in the literature, namely parental depression and parental suicidal ideation, we found that, consistent with the literature, increased risk was also observed in our sample. Although parental depression increased the risk of suicidal behavior in daughters and parental suicidal behavior increased the risk in both sons and daughters, these risks were found to be independent of the association of parental religiosity. This suggests that associations of parental religiosity are independent of these established risk factors of offspring suicidality.

Marital status was found to be associated with lower risk for suicidal behavior in offspring, with offspring of married and remarried parents being less likely to have suicidal behavior. This association was independent of parent religiosity and supports previous findings27 on the importance of a supportive social family structure on childhood suicidal behavior.

As in some previous studies,28 our study also showed that the association of parent’s religiosity, as well as the offspring’s own religiosity, may depend on the offspring’s sex. These findings support the suggestion17 that rather than providing a uniform association, the associations of parents’ religiosity on offspring outcomes may depend on other contextual factors, including the offspring’s sex.

Limitations

Our sample was drawn from the greater New Haven, Connecticut, area and hence was mostly limited to the religious denominations that are highly represented in that community, namely, Catholics and Protestants. The sample was white, and our findings cannot be assumed to generalize to other racial or ethnic groups. Although we had a moderate sample size, the relatively few offspring with suicidal ideation (and even fewer with suicide attempts) precluded examination of the interaction between parent and offspring religiosity on offspring suicidal behavior, as well as the potential moderating associations of parental diagnoses on the association between parent/offspring religiosity and offspring suicidal behaviors. Moreover, given the design of the study, we are unable to make causal claims or rule out the possibility of reverse causality in the associations we have observed.29 This will be left to future research.

Conclusions

Taken together, the findings from this study are unique, as we were able to examine the association of parent and offspring religiosity separately and simultaneously with offspring suicidal behavior. We were also able to investigate whether other parental factors confounded the associations of religiosity. Our findings suggest a parent’s religiosity may be associated with lower suicide ideation and attempts in offspring independent of the offspring’s religiosity and other risk factors. Our data suggest there may be alternative and additional ways to help children and adolescents at highest risk for suicidal behavior. These include conducting a brief spiritual history with parents of offspring being brought in for psychiatric consultations, as well as assessing an offspring’s own beliefs (religious importance) and behaviors (religious service attendance), particularly with girls. Further research examining the mechanism by which parental religiosity is associated with lower risk of suicidal behavior independent of the offspring’s own personal religiosity is warranted. Clinically, the findings suggest that a parent’s belief in religious importance should not be overlooked in considering factors for suicidal behavior.

Back to top Article Information

Accepted for Publication: June 10, 2018.

Corresponding Author: Priya J. Wickramaratne, PhD, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Dr, Unit 24, New York, NY 10032 (priya.wickramaratne@nyspi.columbia.edu).

Published Online: August 8, 2018. doi:10.1001/jamapsychiatry.2018.2060

Correction: This article was corrected on September 5, 2018, to fix typos in the Introduction and Conclusions sections.

Author Contributions: Drs Weissman and Wickramaratne had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Svob and Wickramaratne contributed equally to this manuscript.

Concept and design: Svob, Wickramaratne, Weissman.

Acquisition, analysis, or interpretation of data: Svob, Wickramaratne, Reich, Zhao, Talati, Gameroff, Saeed.

Drafting of the manuscript: Svob, Wickramaratne, Zhao, Talati, Saeed, Weissman.

Critical revision of the manuscript for important intellectual content: Svob, Wickramaratne, Reich, Zhao, Talati, Gameroff, Weissman.

Statistical analysis: Wickramaratne, Reich, Zhao, Talati.

Obtained funding: Weissman.

Administrative, technical, or material support: Svob, Wickramaratne, Gameroff, Weissman.

Supervision: Svob, Wickramaratne, Weissman.

Conflict of Interest Disclosures: In the past 3 years, Dr Weissman received funding from the National Institute of Mental Health, the Sackler Foundation, and the Templeton Foundation and receives royalties from the Oxford University Press, Perseus Press, the American Psychiatric Association Press, and MultiHealth Systems. Dr Saeed’s work was conducted as a visiting researcher at Columbia University. No other disclosures are reported.

Funding/Support: This study was supported in part by the John Templeton Foundation (grant 54679) and the National Institute of Mental Health (grant 2-R01-MH36197) (M.M.W.).

Role of the Funder/Sponsor: The funders did not have a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.