Depression and Suicide Ideation: The Role of Self-Acceptance for Black Young Adults

Abstract

Suicide is a leading cause of death for Black young adults. Though depression is commonly linked to increased risk for suicide, empirical literature examining the depression–suicide association and intrinsic buffers for this association remains limited among Black young adults. This study sought to address this gap in the literature by examining the relationship between depression and suicide ideation among Black young adults. Importantly, this study assessed the moderating role of self-acceptance, an index of how content one is with oneself. Study participants included 123 Black young adults (63.5% female, M_age = 20.91 years, SD = 2.45 years) who completed measures evaluating symptoms of depression, suicide ideation, and psychological well-being. Multivariate regression analyses revealed that self-acceptance moderated the association between depressive symptomatology and suicide ideation (β = −0.05, p < .01, 95% CI [-1.01, −0.11]), such that the depression–suicide ideation association was not significant for individuals who reported high levels of self-acceptance. These findings suggest that self-acceptance may be an important treatment target for interventions aimed specifically at reducing suicide vulnerability among Black young adults.

Keywords

self-acceptance depression suicide Black Americans

Suicide is a public health concern for Black young adults (Centers for Disease Control and Prevention Web Based Injury Statistics Query and Reporting System [CDC WISQARS, 2018). Depression is a robust predictor of various negative mental health outcomes, including suicidality (Morrison & Hopkins, 2019; Walker et al., 2014; Wang, Lightsey, et al., 2013). However, extant depression and suicidality literature has primarily focused on non-Hispanic White samples, and limited research exists on this association for Black young adults. Further, protective factors can assuage negative emotions and should be examined in conjunction with risk-related predictors of suicide ideation (Hollingsworth et al., 2016; Wang, Lightsey, et al., 2013; Williams et al., 2012). While studies have found that self-acceptance is inversely related to depressive symptoms (Jimenez et al., 2010), few studies have examined how self-acceptance might serve as a protective factor that lessens the negative impact of depression on suicidality. The purpose of this study is to examine the moderating effect of self-acceptance on the association between depression and suicide ideation in a sample of Black young adults.

Brief Overview of Black American Suicide

Suicide is the third leading cause of death among Black young adults of age 15 to 24 (CDC WISQARS, 2018). The rate of death for Black young adults of ages 15–24 (10.42/100,000) has increased approximately 35% from 2013 to 2018 (CDC WISQARS, 2018). In a sample of Black college students across four universities, 17% of participants screened positive for two or more suicide risk characteristics (Busby et al., 2019). Further, the lifetime prevalence for suicide ideation among Black Americans is estimated at 11.7%, and over 1/3 of ideators reported attempting suicide (Joe et al., 2006). In one study, conducted in an urban setting, 14.3% of African American young adults reported having considered suicide and 5.3% (61/1150) reported having attempted suicide (Ialongo et al., 2002). Collectively, these reports revealed a relatively high risk for suicidal thoughts and behaviors among Black young adults, including those in university settings who may have access to more resources.

Research suggests that a myriad of factors contribute to suicide risk. However, specific risk factors are associated with suicide ideation and attempts among Black young adults, including lower ethnic identity, alienation from family, fragmentation of social support, racial microaggressions, and decreased religiosity/religious beliefs (Compton et al., 2005; Hollingsworth et al., 2017; Perez-Rodriguez et al., 2008; Walker et al., 2017). Brooks et al. (2020) found that perceived discrimination was associated with suicide capability for Black, but not White university students. Black college students also attempt suicide more often, although they disclose suicidality less readily than their White counterparts (Morrison & Downey, 2000; Wang, Lightsey, et al., 2013).

Black young adults also report risk factors identified in the general population. In one study, hopelessness was strongly associated with suicide attempts for both Black and White young adults, although the odds were greater for Black young adults (Durant et al., 2006). In addition to hopelessness, the literature suggests that reporting negative life events, psychiatric disorders, and identifying as female are all associated with a higher risk for suicidality (Ialongo et al., 2002; Joe et al., 2006; Kaslow et al., 2000). Depression and depressive symptoms are also indicated as risk factors for suicide (Compton et al., 2005; Kaslow et al., 2002; Thompson et al., 2002). Of note, the vast majority of people who die by suicide (approximately 95%) are said to suffer from mental disorders (Cavanagh et al., 2003). Specifically, depression is the most common psychiatric disorder in people who die by suicide (Hawton et al., 2013). Despite these studies, however, there is a limited understanding of the association between depression and suicidality among Black Americans, as well as protective factors that may mitigate this effect.

Depression as a Predictor for Suicidality

Epidemiological reports indicate that depressive disorders have a more chronic course for Black Americans compared to non-Hispanic Whites (González et al., 2010; Hankerson et al., 2011; Watkins et al., 2015). Specifically, Black Americans diagnosed with Major Depressive Disorder (MDD) have significantly higher odds of comorbid insomnia, hypertension, and liver disease (Hankerson et al., 2011). Consistent with these findings, the association between MDD and heart disease is more prominent among Black adults than White adults in the United States (Assari, 2014). Racial differences in depressive symptomatology have also been noted, as Black Americans who meet criteria for MDD are less likely to report fatigue or loss of energy, and cognitive symptoms, including indecisiveness and worthlessness (Hankerson et al., 2011). By contrast, sleep disturbance, loss of appetite, and loss of libido are stronger manifestations of depression for Black Americans (Ayalon & Young, 2003). The higher chronicity and morbidity of depression has been attributed to Black Americans being less likely to receive outpatient services, be prescribed medications for MDD, or receive emergency room and inpatient treatment (Hankerson et al., 2011). Racial differences in depressive symptomatology, comorbidity, and treatment may also be explained by Black Americans’ increased exposure to known predictors of depression, including social marginalization (via racial discrimination), persistent poverty, social isolation, or decreased access to community resources (Gibbs, 1997; Klonoff et al., 1999; Taylor & Turner, 2002).

Importantly, depression is a robust predictor of negative physical health and mental health outcomes, including suicide ideation and behavior (Bolton et al., 2010; Goldsmith et al., 2002; Hawton et al., 2013; Kessler et al., 1999; McGirr et al., 2008; Van Orden et al., 2010; Verona et al., 2004). Studies of suicide reveal that 15% of individuals with MDD have attempted suicide at some point during their life (Chen & Dilsaver, 1996), and that approximately 60% of individuals who die by suicide suffer from depression (Cavanagh et al., 2003; Lesage et al., 1994). Additionally, among depressed individuals, approximately one-quarter make a non-fatal suicide attempt during their lifetime (Verona et al., 2004).

Consistent with broader literature, depression is a risk factor for suicidality among Black Americans (Compton et al., 2005; Ialongo et al., 2002; Kimbrough et al., 1996; Lester, 1999; Palmer, 2001; Walker et al., 2008). Walker et al. (2014) found that depression mediated the association between perceived racism and suicide ideation for African American adults. Depression has also been demonstrated to be a strong predictor of suicidal behavior among Black college students (Wang, Lightsey, et al., 2013). In considering depression and suicide among Black Americans, it is imperative to examine protective factors that help mitigate this effect for this at-risk population.

The Moderating Role of Self-Acceptance

Self-acceptance is defined as the ability to positively evaluate oneself and their life, while acknowledging the presence of good and bad qualities within oneself (Edmondson & MacLeod, 2015; Ryff, 1989). One’s level of self-acceptance does not hinge on the approval or opinions of others, but instead is based on internal feelings despite failures and successes (Ryff, 1989). As Butler-Barnes et al. (2013) and Ellis (1995) denote, strengthening an individual’s self-acceptance beliefs can be viewed as the cornerstone of psychological well-being, as having a healthy self-acceptance allows individuals to make mistakes and experience rejection without experiencing psychological distress. Experiences of self-acceptance have been shown to reinforce resilience among people of African descent (Bauermeister et al., 2007; Butler-Barnes et al., 2013; Frazier et al., 2005; Thompson, 2006). Importantly, self-acceptance has demonstrated congruence with religiosity and mindfulness, two robust coping mechanisms for Black Americans (Frazier et al., 2005; Jimenez et al., 2010; Steger & Frazier, 2005).

Self-acceptance is one of the six key components of the model of psychological well-being (Ryff, 1989, 2014). From this perspective, an individual’s sense of self-acceptance is a central feature of mental health, as well as a characteristic of optimal functioning and self-actualization (Ryff, 1989). Relative to depression and suicide research, according to Beck (1974), a lack of self-acceptance is central to depressive disorders. Flett et al. (2003) demonstrated that unconditional self-acceptance mediates the path from socially prescribed perfectionism to depression. Higher levels of self-acceptance also seem to be associated with less suicide ideation and behavior (Heisel & Flett, 2008; Walker et al., 2009). However, very few studies have explored the relationship between self-acceptance and either depression or suicide risk among Black Americans (Yoon et al., 2019; Zhang et al., 2018, 2019). Additionally, no known study has explored self-acceptance, depression, and suicidality among Black young adults. Given the adaptive role of self-acceptance for Black Americans, an examination of its potential effect in the context of suicide risk is warranted.

Current Study

The increasing suicide rate among Black young adults has resulted in a call for increased empirical examinations of suicidal behavior, and contributing risk and resilience factors, within this population. Past research has established depression as one of the most prominent risk factors for suicide ideation among racially and ethnically diverse samples (Bolton et al., 2010; Goldsmith et al., 2002; Hawton et al., 2013; Kessler et al., 1999; McGirr et al., 2008; Van Orden et al., 2010; Verona et al., 2004). Furthermore, extant literature has established that self-acceptance has a positive impact in numerous domains of functioning for Black Americans (e.g., depressive symptoms, psychological well-being, and academic achievement; Bauermeister et al., 2007; Butler-Barnes et al., 2013; Frazier et al., 2005; Thompson, 2006), to the extent of potentially protecting against suicidal behaviors (Wang, Joel Wong et al., 2013). However, no known study has explored self-acceptance, depression, and suicidality among Black young adults. Thus, the purpose of the current study was to evaluate the potential moderating effect of self-acceptance on the association between depressive symptoms and suicide ideation among Black young adults. Previous studies have demonstrated age and gender effects on suicide ideation for young adults (Hollingsworth et al., 2017; Silenzio et al., 2007; Wetherall et al., 2018). As such, age and gender were included as covariates in this model. The specific hypotheses for the study were as follows:

H1: Higher levels of depressive symptomatology would be associated with

higher levels of suicide ideation.

H2: Self-acceptance will moderate the association between depressive symptomatology and suicide ideation, wherein greater self-acceptance will be associated with a decreased association between depressive symptoms and suicide ideation.

Method

Participants

Participants included 123 Black young adults (63.5% female, M_age = 20.91 years, SD = 2.45 years) recruited from a large public university in the southern United States. The data employed in the current study are based upon a subsample from a larger study of stress and health behaviors among college students. To test the present study hypotheses, only data for 18–30-year-old participants who identified as Black and non-Hispanic/Latinx, and completed all measures of interest, were included in the present study.

Measures

Demographics

The participants were asked demographic questions to measure age, gender, race/ethnicity, marital status, and generational status.

Beck Depression Inventory-II (BDI-II)

The BDI-II (Beck et al., 1996) is a 21-item self-report instrument that assesses the severity of depressive symptomatology in the past week (e.g., “I blame myself for everything bad that happens”). Respondents’ scores are rated on a Likert-type scale ranging from 0 to 3, with higher scores indicating greater severity of symptoms. Respondents’ ratings of the BDI-II items are summed to form total scores, which range from 0 to 63. Total scores on the BDI-11 of 13–19 are considered to represent dysphoric mood, whereby BDI-II scores greater than 19 suggest risk for clinical symptoms of depression (Dozois et al., 1998). Past research using the BDI-II has reported high internal consistency in an African American young adult sample (α = .93; Madubata et al., 2018) as well as college and community samples, with alpha values ranging from .89 to .93 (M = .91; Abela et al., 2006; Segal et al., 2008). Tests of convergent validity of the BDI-II within Black populations indicate a strong correlation between the BDI-II and other measures of depression (Joe et al., 2008). Although no known tests of discriminant validity have been conducted for the BDI-II in primarily Black American samples, discriminant validity of the BDI-II has been demonstrated through weaker relationships with measures of other psychopathology, such as anxiety (Coles et al., 2001). In the current study, tests for internal consistency were similar to previous studies (α = .94).

Adult Suicidal Ideation Questionnaire (ASIQ)

The ASIQ (Reynolds, 1991) is a 25-item self-report measure of the severity of suicide ideation in adults aged 18 and older. Participants were asked to respond on a seven-point scale regarding the frequency of suicidal thoughts ranging from 0 (never had the thought) to 6 (had the thought almost every day). A total score is produced by summing the ratings, with higher scores reflecting greater levels of suicide ideation. The scale has shown high reliability data for a community of adults and college student samples with alpha values ranging from .97 to .98 (Fu & Yip, 2007; Reynolds, 1991) and among racial and ethnic minorities (α = .96–.98; Walker et al., 2014). Though reliability estimates have been reported with Black populations, no known tests of validity have been conducted for the ASIQ amongst primarily Black samples. However, the ASIQ has been found to correlate significantly with the related constructs of depression, hopelessness, anxiety, self-esteem, and history of prior suicide attempts, providing evidence of convergent validity (Osman et al., 1999). Tests of discriminant validity reveal weak negative correlations between the Suicide Risk Assessment Checklist (SRAC) protective items and the ASIQ (Horon et al., 2013). In the current study, α = .98 and is indicative of good internal consistency.

Psychological Well-Being Scale (PWB)—Self-acceptance subscale

The psychological well-being scale (PWB) is a 42-item self-report instrument designed to assess an individual’s level of psychological functioning (Ryff & Keyes, 1995). The self-acceptance subscale (7 items), one of six dimensions measured in the PWB, assesses positive evaluations of oneself and the way that they have lived their life. Participants respond to questions such as “When I look at the story of my life, I am pleased with how things have turned out” and “In general, I feel confident and positive about myself.” Each item is rated on a Likert scale, ranging from 1 (strongly disagree) to 6 (strongly agree). Summing the items produces a score for the subscale, higher scores indicating higher levels of life purpose. The subscale has been reported to have high internal consistency (α = .95; Akin, 2008) and has been utilized in studies of African American and Mexican American samples (α = .95; Butler-Barnes et al., 2017). Though reliability estimates have been reported with Black populations, no known tests of validity have been conducted for the PWB amongst primarily Black samples. However, according to Ryff and Keyes (1995), each dimension of the PWB has demonstrated convergent and discriminant validity with other measures. For the current study, the Cronbach’s alpha was .88 and indicative of good internal consistency reliability.

Procedure

The present study was granted institutional review board approval. Upon informed consent, participants completed a computerized battery of online questionnaires. Approximately 30 minutes were required to complete the online survey. Each participant received extra course credit or fulfillment of a course requirement as incentive for participating in the study. Persons who were less than 18 years of age, over 30 years of age, or who did not identify as Black/African American were not included in the study. Among this subsample of students (N = 126), three were removed due to invalid responding, for a final sample size of 123. Responses were considered invalid if participants endorsed the wrong response option for two validation questions (e.g., “If the University of Houston is located in the US, select Strongly Agree”) included in the primary measures of interest.

Results

Preliminary Analysis

Analyses were conducted using IBM SPSS version 27.0. First, the data were examined for normality and missingness. Little’s missing completely at random (MCAR) test was non-significant (χ²(4) = 3.59, p = .308), suggesting it was reasonable to treat the data as missing completely at random. Therefore, list-wise deletion was employed for missing data. Tests of normality assumptions showed that the data were normally distributed. Power analyses were computed to indicate that the participant sample size surpassed the minimum sample size required to achieve β = .80, given a medium effect size (Faul et al., 2007). To capture a young adult sample, participants who were more than 30 years old were not included in the analyses. Means, SDs, and intercorrelations for all measured variables are presented in Table 1. BDI-II scores for approximately 24% of the sample suggest risk for clinical symptoms of depression (BDI-II scores greater than 19). An additional 15% of the sample reported symptoms of dysphoria (BDI-II scores ranging from 13 to 19) (Dozois et al., 1998). As expected, bivariate correlation analyses revealed a significant positive association between symptoms of depression and suicide ideation (r = .62, p <.01), such that higher self-reported depressive symptomatology was related to higher levels of suicide ideation. Furthermore, as indicated in Table 1, self-acceptance was inversely associated with symptoms of depression (r = −.60, p < .01) and suicide ideation (r = −.47, p < .01), such that higher ratings of self-acceptance related to lower depressive symptomatology and lower suicide ideation.

Table 1.

Descriptive Statistics and Bivariate Correlations Between Study Variables for Black American Adults (N = 123).

Variable	1	2	3	4	5	M	SD
1. BDI-II	—					12.25	11.63
2. ASIQ	.62**	—				12.43	20.45
3. Self-Acceptance	−.60**	−.47**	—			28.68	8.04
4. Age	−.08	−.03	.10	—		20.91	2.45
5. Gender^a	.16	.12	−.05	−.05	—	—	—

Note. BDI-II = Beck Depression Inventory-II total score (Beck, Steer, & Brown, 1996); ASIQ = Adult Suicidal.

Ideation Questionnaire (Reynolds, 199l); The Psychological Well-Being Scale-self-acceptance subscale.

score (Ryff & Keyes, 1995); ^aDemographics questionnaire (0=male; 1=female).

*p < .05. **p < .01.

Tests of Main Effects and Moderation

Main effects and moderation analyses were conducted to examine the moderating effect of self-acceptance on the association between depressive symptoms and suicide ideation for Black young adults. All analyses were conducted with mean-centered variables using PROCESS macro version 3 (Preacher & Hayes, 2008). The order of entry in the hierarchical regression model was as follows: age and gender were entered simultaneously as covariates in Step 1. BDI-II scores and PWB self-acceptance scores were entered simultaneously in Step 2 to assess potential main effects of depressive symptomatology and self-acceptance on suicide ideation. The interactive effect of depressive symptomatology and self-acceptance was entered in Step 3. The significant change in R² for the interaction term indicated the significant moderator effect. The results of these analyses are presented in Table 2.

Table 2.

Hierarchical Regression Analysis of Depressive Symptomatology and Self-Acceptance Predicting Suicide Ideation Among Black American Adults (N = 123).

Model Step and Variable	β	R ²	ΔR²	t	p	Bootstrapped 95% CI		Semi-partial correlations
Step 1		.02
Age	−.04			−.41	.69	−1.81	1.19	−.04
Gender^a	.13			1.46	.15	−2.00	13.30	.13
Step 2		.41	.39**
BDI-II	.53			5.95	<.001**	.63	1.25	.42
Self-acceptance	−.15			−1.65	.10	−.83	.08	−.12
Step 3		.46	.05*
BDI-II x self-acceptance	−.63			−3.16	.002*	−.09	−.02	−.28

Note.^aDemographics questionnaire (0=male; 1=female); . BDI-II = Beck Depression Inventory-II total score (Beck, Steer, & Brown, 1996); The Psychological Well-Being Scale-self-acceptance subscale score (Ryff & Keyes, 1995).

*p < .01, **p < .001.

Analyses indicated that depressive symptomatology significantly predicted suicide ideation (β = .53, p < .001). Moreover, a significant interaction between depression and self-acceptance predicting suicide ideation was found F(1, 117) = 10.01, p = .002, 95% CI [-.09, −0.02]), such that the relation between depressive symptomatology and suicide ideation varied depending on one’s level of reported self-acceptance. This overall model accounted for approximately 46% of the variance in predicting suicide ideation among Black young adults (R² = 0.46, p = .002, Table 2).

To further explore the nature of the interactive effect of depressive symptomatology and self-acceptance in predicting suicide ideation for Black young adults, the cross-products of these variables were plotted (see Figure 1). Additionally, specific regions of significance were determined using the Johnson–Neyman technique (Aiken & West, 1991; Hayes & Rockwood, 2017; Johnson & Fay, 1950). This method identifies specific regions of significance and has been noted to be superior to other probing methods that identify arbitrary low and high levels of the moderator (Hayes, 2013; Hayes & Rockwood, 2017). This analysis revealed that when participants had a centered self-acceptance score of 3.29 (approximately +0.5 SD) or lower, the relationship between depressive symptomatology and suicide ideation was significant (β = 1.04, p < .001). At high levels of self-acceptance (above a centered score of 3.29), the association between depressive symptomatology and suicide ideation was not significant (β = .18, p = .52). Thus, the association between depressive symptomatology and suicide ideation varied according to specific levels of self-acceptance.

Figure 1.

Interaction between depressive symptoms and self-acceptance predicting suicide ideation (N = 123). Low depressive symptoms are plotted at 1 SD below the mean. High depressive symptoms are plotted at 1 SD above the mean.

Discussion

The overall aim of the current study was to (a) investigate the association of depressive symptoms and suicide ideation and (b) examine the potential moderating effect of self-acceptance for Black young adults. As hypothesized, the current study found that elevated symptoms of depression were associated with more frequent suicide ideation among Black young adults. This finding is consistent with prior research on depression as a risk factor for suicide and related behavior (e.g., Beck et al., 1975; Gotlib & Hammen, 2015; Joiner, 2005; Ribeiro et al., 2018; Van Orden et al., 2010). Potential explanations for this association include diminished psychological functioning (i.e., impaired coping skills; Nrugham et al., 2012) and underlying cognitive mechanisms such as hopelessness and rumination (Abramson et al., 2002; Cheref et al., 2015; Marco et al., 2016; Qiu et al., 2017; Steeg et al., 2016). For Black young adults in particular, race-related stressors may also exacerbate depressive symptoms and, subsequently, suicide risk (Polanco-Roman & Miranda, 2013; Walker et al., 2014, 2017). As Black Americans experience more chronic depressive episodes and increasing rates of suicide behavior in recent years, it is important to address potential protective factors unique to this population.

Our second hypothesis was also fully supported, in that perceived self-acceptance moderated the association between depressive symptoms and suicide ideation for Black young adults. Specifically, symptoms of depression were not associated with thoughts of suicide among persons who reported higher self-acceptance in the current study. Consistent with previous literature, this finding suggests self-acceptance may be an important internal regulatory dimension of one’s self-concept; holding positive and realistic attitudes toward the self protects against external influences that may invoke psychological distress (Ryff, 1989). For example, in a sample of Black adolescents, Butler-Barnes et al. (2013) observed that academic persistence after experiencing school-based racial discrimination was significantly higher for children with increased self-acceptance, highlighting that self-acceptance has importance beginning in adolescence. Furthermore, in a sample of older African Americans, Yoon et al. (2019) demonstrated that self-acceptance was a significant mediator in the relationship between discrimination and mental health problems, providing evidence that targeting self-acceptance in psychological interventions can reduce the negative impact of race-related stress on mental health for older African Americans. Importantly, this is the first known study that explicitly considers self-acceptance as a moderating factor of negative mental health outcomes for Black young adults who demonstrate elevated risk for suicide ideation. Further, this study supports previous self-acceptance literature as negatively associated with thoughts of suicide (Gonçalves et al., 2016; Heisel & Flett, 2008; Ioannou & Debowska, 2014; Walker et al., 2009). For Black Americans, who are disproportionately exposed to race-related stressors in addition to other known psychosocial predictors of depression (i.e., social support deficits and poverty; Keita, 2007), it could be suggested that high self-acceptance validates their personhood and counteracts feelings of hopelessness associated with perceived low self-worth and race-related stressors.

Importantly, a significant proportion of the sample exhibited dysphoric and more severe depressive symptoms (as indicated by BDI-II scores of 13 and greater). In a non-clinical sample, the percentage of Black American individuals exhibiting sub-clinical and clinical depressive symptoms is high relative to previous studies (cf. Hooper et al., 2012); however, more recent studies reflect comparable ratios (e.g., Madubata et al., 2018). This observed increase in reports of dysphoric and severe depressive symptoms is indicative of poor psychological well-being in a considerable proportion of Black individuals meriting further examination into risk and protective factors of depression among this at-risk population.

The current study has notable clinical implications. Clinically, the study findings suggest self-acceptance to be an important treatment target for interventions (e.g., strengths-based approaches; Yoon et al., 2019) aimed specifically at Black young adults. For example, psychotherapists may implement treatment approaches highlighting self-acceptance and its benefits to increase feelings of self-worth for Black patients and clients. Existing interventions that highlight self-acceptance include rational emotive behavioral therapy (REBT; Ellis, 1995), which emphasizes unconditional self-acceptance through objective thought analysis, and third-wave cognitive behavioral interventions (e.g., Acceptance and Commitment Therapy, Mindfulness-based Cognitive Therapy, etc.; Hayes et al., 2009; Segal et al., 2002), which emphasize nonjudgmental acceptance of the self and the environment. Existing literature on mindfulness-based interventions for Black Americans shows promising work on mindfulness as a means of instilling nonjudgmental self-acceptance and improving emotion regulation (Sibinga et al., 2011; Woods-Giscombé & Black, 2010; Woods-Giscombé & Gaylord, 2014).

Limitations and Future Research

Although this study expands on the scientific literature for depression, self-acceptance, and suicide ideation among African Americans, it is not without limitations. First, given the cross-sectional nature of the data, definitive causal modeling inferences are limited. As this is a preliminary study in examining the moderating role of self-acceptance, future studies would benefit from utilizing a longitudinal approach and investigating whether suicide ideation for Black Americans remains stable across time, varies as a function of depressive symptomatology, or fluctuates with self-acceptance. Second, the current study did not examine race-related variables, such as racial identity and racial socialization, that have been shown to buffer the effects of depression among Black Americans (Butler-Barnes et al., 2013; Phinney, 1990; Williams et al., 2012). Specifically, racial socialization influences racial identity development and reinforces racial pride, which encourages self-acceptance for one’s racial background (Neblett et al., 2013; Phinney, 1990; Reynolds & Gonzalez-Backen, 2017). Future research can examine culturally meaningful variables that have shown to increase resiliency for Black American adults, which would further provide culturally informed explanations for the depression–suicide ideation association. Third, measures in this study were presented in the same order to all study participants. Future studies might employ randomization of measures to eliminate potential response bias. Last, the study recruited primarily from a university population, which limits the study’s generalizability. Because the sample demonstrated significant depression symptomatology in a non-clinical sample, future studies would benefit from comparing the moderating effects of self-acceptance on the depression–suicide association between community and clinical samples of Black American adults.

Conclusions

This study provides novel insight into underlying regulatory mechanisms for depressive symptoms and suicide behavior in Black American young adults. The current findings highlight the importance of considering the impact of self-acceptance, or a positive self-concept, on emotion regulation for individuals experiencing psychological distress. Several lines of evidence point to high self-acceptance and self-worth as critical in maximizing resilience and psychological well-being (Butler-Barnes et al., 2013; Ryff, 1989). As depression and suicide behavior are public health problems for Black young adults, it is imperative for future research and clinical work to identify and utilize protective factors that ultimately validate one’s self-worth and personhood.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jasmin R. Brooks

References

Abela

J. R. Z.

Webb

C. A.

Wagner

M.-H. R.

Adams

(2006). The role of self-criticism, dependency, and hassles in the course of depressive illness: A multiwave longitudinal study. Personality and Social Psychology Bulletin, 32(3), 328-338. https://doi.org/10.1177/0146167205280911

Abramson

L. Y.

Alloy

L. B.

Hogan

M. E.

Whitehouse

W. G.

Gibb

B. E.

Hankin

B. L.

Cornette

M. M.

(2002). The hopelessness theory of suicidality. In Joiner

Rudd

M. D.

(Eds.), Suicide science (pp. 17-32). Springer. https://doi.org/10.1007/0-306-47233-3_3

Aiken

L. S.

West

S. G.

(1991). Multiple regression: Testing and interpreting interactions. Sage.

Akin

(2008). The scales of psychological well-being: A study of validity and reliability. Educational Sciences: Theory and Practice, 8(3), 741-750.

Assari

(2014). Chronic medical conditions and major depressive disorder: Differential role of positive religious coping among African Americans, Caribbean blacks and non-Hispanic Whites. International Journal of Preventive Medicine, 5(4), 405-413.

Ayalon

Young

M. A.

(2003). A comparison of depressive symptoms in African Americans and Caucasian Americans. Journal of Cross-Cultural Psychology, 34(1), 111-124. https://doi.org/10.1177/0022022102239158

Bauermeister

J. A.

Zimmerman

M. A.

Barnett

T. E.

Caldwell

C. H.

(2007). Working in high school and adaptation in the transition to young adulthood among African American youth. Journal of Youth and Adolescence, 36(7), 877-890. https://doi.org/10.1007/s10964-007-9196-0

Beck

A. T.

(1974). The development of depression: A cognitive model. In Friedman

R. J.

Katz

M. M.

(Eds.), The psychology of depression: Contemporary theory and research (pp. 318-330). John Wiley.

Beck

A. T.

Kovacs

Weissman

(1975). Hopelessness and suicidal behavior. JAMA, 234(11), 1146-1149. https://doi:10.1001/jama.1975.03260240050026

10.

Beck

A. T.

Steer

R. A.

Brown

G. K.

(1996). Beck Depression Inventory-II. Psychological Corporation.

11.

Bolton

J. M.

Pagura

Enns

M. W.

Grant

Sareen

(2010). A population-based longitudinal study of risk factors for suicide attempts in major depressive disorder. Journal of Psychiatric Research, 44(13), 817-826. https://doi.org/10.1016/j.jpsychires.2010.01.003

12.

Brooks

J. R.

Hong

J. H.

Cheref

Walker

R. L.

(2020). Capability for suicide: Discrimination as a painful and provocative event. Suicide and Life-Threatening Behavior, 50, 1173-1180. https://doi.org/10.1111/sltb.12671

13.

Busby

D. R.

Zheng

Eisenberg

Albucher

R. C.

Favorite

Coryell

King

C. A.

(2019). Black college students at elevated risk for suicide: Barriers to mental health service utilization. Journal of American College Health, 36(1), 1-7. https://doi.org/10.1080/07448481.2019.1674316

14.

Butler-Barnes

S. T.

Chavous

T. M.

Hurd

Varner

(2013). African American adolescents' academic persistence: A strengths-based approach. Journal of Youth and Adolescence, 42(9), 1443-1458. https://doi.org/10.1007/s10964-013-9962-0

15.

Butler-Barnes

S. T.

Martin

P. P.

Boyd

D. T.

(2017). African American adolescents’ psychological well-being: The impact of parents’ religious socialization on adolescents’ religiosity. Race and Social Problems, 9(2), 115-126. https://doi.org/10.1007/s12552-017-9199-8

16.

Cavanagh

J. T. O.

Carson

A. J.

Sharpe

Lawrie

S. M.

(2003). Psychological autopsy studies of suicide: A systematic review. Psychological Medicine, 33(3), 395-405. https://doi.org/10.1017/s0033291702006943

17.

Centers for Disease Control and Prevention CDC, National Center for Injury Prevention and Control Data & Statistics Fatal injury report (2018). Web-based Injury Statistics Query and reporting System (WISQARS).

18.

Chen

Y.-W.

Dilsaver

S. C.

(1996). Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other axis I disorders. Biological Psychiatry, 39(10), 896-899. https://doi.org/10.1016/0006-3223(95)00295-2

19.

Cheref

Lane

Polanco-Roman

Gadol

Miranda

(2015). Suicidal ideation among racial/ethnic minorities: Moderating effects of rumination and depressive symptoms. Cultural Diversity and Ethnic Minority Psychology, 21(1), 31-40. https://doi.org/10.1037/a0037139

20.

Coles

M. E.

Gibb

B. E.

Heimberg

R. G.

(2001). Psychometric evaluation of the Beck Depression Inventory in adults with social anxiety disorder. Depression and Anxiety, 14(2), 145-148. https://doi.org/10.1002/da.1057

21.

Compton

M. T.

Thompson

N. J.

Kaslow

N. J.

(2005). Social environment factors associated with suicide attempt among low-income African Americans: The protective role of family relationships and social support. Social Psychiatry and Psychiatric Epidemiology, 40(3), 175-185. https://doi.org/10.1007/s00127-005-0865-6

22.

Dozois

D. J. A.

Dobson

K. S.

Ahnberg

J. L.

(1998). A psychometric evaluation of the Beck Depression Inventory-II. Psychological Assessment, 10(2), 83-89. https://doi.org/10.1037/1040-3590.10.2.83

23.

Durant

Mercy

Kresnow

M.-j.

Simon

Potter

Hammond

W. R.

(2006). Racial differences in hopelessness as a risk factor for a nearly lethal suicide attempt. Journal of Black Psychology, 32(3), 285-302. https://doi.org/10.1177/0095798406290468

24.

Edmondson

O. J. H.

MacLeod

A. K.

(2015). Psychological well-being and anticipated positive personal events: Their relationship to depression. Clinical Psychology & Psychotherapy, 22(5), 418-425. https://doi.org/10.1002/cpp.1911

25.

Ellis

(1995). Rational emotive behavior therapy. In Corsini

Wedding

(Eds.), Current psychotherapies (5th ed., pp. 162-196). Peacock.

26.

Faul

Erdfelder

Lang

A.-G.

Buchner

(2007). G*power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175-191. https://doi.org/10.3758/bf03193146

27.

Flett

G. L.

Besser

Davis

R. A.

Hewitt

P. L.

(2003). Dimensions of perfectionism, unconditional self-acceptance, and depression. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 21(2), 119-138. https://doi.org/10.1023/A:1025051431957

28.

Frazier

Mintz

L. B.

Mobley

(2005). A multidimensional look at religious involvement and psychological well-being among urban elderly African Americans. Journal of Counseling Psychology, 52(4), 583-590. https://doi.org/10.1037/0022-0167.52.4.583

29.

K.-w.

Yip

P. S. F.

(2007). Long-term impact of celebrity suicide on suicidal ideation: Results from a population-based study. Journal of Epidemiology & Community Health, 61(6), 540-546. https://doi.org/10.1136/jech.2005.045005

30.

Gibbs

J. T.

(1997). African-American suicide: A cultural paradox. Suicide & Life-Threatening Behavior, 27(1), 68-79. https://doi.org/10.1111/j.1943-278X.1997.tb00504.x

31.

Goldsmith

S. K.

Pellmar

T. C.

Kleinman

A. M.

Bunney

W. E.

(Eds.). (2002). Reducing suicide: A national imperative. National Academies Press.

32.

González

H. M.

Tarraf

Whitfield

K. E.

Vega

W. A.

(2010). The epidemiology of major depression and ethnicity in the United States. Journal of Psychiatric Research, 44(15), 1043-1051. https://doi.org/10.1016/j.jpsychires.2010.03.017.

33.

Gonçalves

A. M.

da Cruz Sequeira

C. A.

Duarte

J. C.

de Freitas

P. P.

(2016). Suicidal ideation on higher education students: Influence of some psychosocial variables. Archives of Psychiatric Nursing, 30(2), 162-166. https://doi.org/10.1016/j.apnu.2015.08.005.

34.

Gotlib

I. H.

Hammen

C. L.

(Eds.), (2015). Handbook of depression (3rd ed.). Guilford Press.

35.

Hankerson

S. H.

Fenton

M. C.

Geier

T. J.

Keyes

K. M.

Weissman

M. M.

Hasin

D. S.

(2011). Racial differences in symptoms, comorbidity, and treatment for major depressive disorder among black and white adults. Journal of the National Medical Association, 103(7), 576-584. https://doi.org/10.1016/s0027-9684(15)30383-7

36.

Hawton

Casañas I Comabella

Haw

Saunders

(2013). Risk factors for suicide in individuals with depression: A systematic review. Journal of Affective Disorders, 147(1–3), 17-28. https://doi.org/10.1016/j.jad.2013.01.004

37.

Hayes

A. F.

(2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford Press.

38.

Hayes

A. F.

Rockwood

N. J.

(2017). Regression-based statistical mediation and moderation analysis in clinical research: Observations, recommendations, and implementation. Behaviour Research and Therapy, 98, 39-57. https://doi.org/10.1016/j.brat.2016.11.001

39.

Hayes

S. C.

Strosahl

K. D.

Wilson

K. G.

(2009). Acceptance and commitment therapy. American Psychological Association.

40.

Heisel

M. J.

Flett

G. L.

(2008). Psychological resilience to suicide ideation among older adults. Clinical Gerontologist, 31(4), 51-70. https://doi.org/10.1080/07317110801947177

41.

Hollingsworth

D. W.

Cole

A. B.

O'Keefe

V. M.

Tucker

R. P.

Story

C. R.

Wingate

L. R.

(2017). Experiencing racial microaggressions influences suicide ideation through perceived burdensomeness in African Americans. Journal of Counseling Psychology, 64(1), 104-111. https://doi.org/10.1037/cou0000177

42.

Hollingsworth

D. W.

Wingate

L. R.

Tucker

R. P.

O’Keefe

V. M.

Cole

A. B.

(2016). Hope as a moderator of the relationship between interpersonal predictors of suicide and suicidal thinking in African Americans. Journal of Black Psychology, 42(2), 175-190. https://doi.org/10.1177/0095798414563748

43.

Hooper

L. M.

Crusto

C. A.

Huffman

L. E.

(2012). Scalar equivalence in self-rated depressive symptomatology as measured by the Beck Depression Inventory-II: Do racial and gender differences in college students exist? Psychology, 3(9A), 762-774. https://doi.org/10.4236/psych.2012.329116

44.

Horon

McManus

Schmollinger

Barr

Jimenez

(2013). A study of the use and interpretation of standardized suicide risk assessment: Measures within a psychiatrically hospitalized correctional population. Suicide and Life-Threatening Behavior, 43(1), 17-38. https://doi.org/10.1111/j.1943-278X.2012.00124.x

45.

Ialongo

McCreary

B. K.

Pearson

J. L.

Koenig

A. L.

Wagner

B. M.

Schmidt

N. B.

Poduska

Kellam

S. G.

(2002). Suicidal behavior among urban, African American young adults. Suicide and Life-Threatening Behavior, 32(3), 256-271. https://doi.org/10.1521/suli.32.3.256.22176

46.

Ioannou

Debowska

(2014). Genuine and simulated suicide notes: An analysis of content. Forensic Science International, 245, 151-160. https://doi.org/10.1016/j.forsciint.2014.10.035

47.

Jimenez

S. S.

Niles

B. L.

Park

C. L.

(2010). A mindfulness model of affect regulation and depressive symptoms: Positive emotions, mood regulation expectancies, and self-acceptance as regulatory mechanisms. Personality and Individual Differences, 49(6), 645-650. https://doi.org/10.1016/j.paid.2010.05.041

48.

Joe

Baser

R. E.

Breeden

Neighbors

H. W.

Jackson

J. S.

(2006). Prevalence of and risk factors for lifetime suicide attempts among Blacks in the United States. JAMA, 296(17), 2112-2123. https://doi.org/10.1001/jama.296.17.2112

49.

Joe

Woolley

M. E.

Brown

G. K.

Ghahramanlou-Holloway

Beck

A. T.

(2008). Psychometric properties of the Beck Depression Inventory-II in low-income, African American suicide attempters. Journal of Personality Assessment, 90(5), 521-523. https://doi.org/10.1080/00223890802248919

50.

Johnson

P. O.

Fay

L. C.

(1950). The Johnson-Neyman technique, its theory and application. Psychometrika, 15(4), 349-367. https://doi.org/10.1007/BF02288864

51.

Joiner

(2005). Why people die by suicide. Harvard University Press.

52.

Kaslow

N. J.

Thompson

M. P.

Brooks

A. E.

Twomey

H. B.

(2000). Ratings of family functioning of suicidal and nonsuicidal African American women. Journal of Family Psychology, 14(4), 585-599. https://doi.org/10.1037/0893-3200.14.4.585

53.

Kaslow

N. J.

Thompson

M. P.

Okun

Price

Young

Bender

Wyckoff

Twomey

Goldin

Parker

(2002). Risk and protective factors for suicidal behavior in abused African American women. Journal of Consulting and Clinical Psychology, 70(2), 311-319. https://doi.org/10.1037/0022-006X.70.2.311

54.

Keita

G. P.

(2007). Psychosocial and cultural contributions to depression in women: Considerations for women midlife and beyond. Journal of Managed Care Pharmacy, 13(9), S12-S15. https://doi.org/10.18553/jmcp.2007.13.9-a.12

55.

Kessler

R. C.

Mickelson

K. D.

Williams

D. R.

(1999). The prevalence, distribution, and mental health correlates of perceived discrimination in the United States. Journal of Health and Social Behavior, 40(3), 208-230. https://doi.org/10.2307/2676349

56.

Kimbrough

R. M.

Molock

S. D.

Walton

(1996). Perception of social support, acculturation, depression, and suicidal ideation among African American college students at predominantly Black and predominantly White universities. The Journal of Negro Education, 65(3), 295-307. https://doi.org/10.2307/2967346

57.

Klonoff

E. A.

Landrine

Ullman

J. B.

(1999). Racial discrimination and psychiatric symptoms among Blacks. Cultural Diversity & Ethnic Minority Psychology, 5(4), 329-339. https://doi.org/10.1037/1099-9809.5.4.329

58.

Lesage

A. D.

Boyer

Grunberg

Vanier

Morissette

Ménard-Buteau

Loyer

(1994). Suicide and mental disorders: A case-control study of young men. American Journal of Psychiatry, 151(7), 1063-1068. https://doi.org/10.1176/ajp.151.7.1063

59.

Lester

(1999). Locus of control and suicidality. Perceptual and Motor Skills, 89(3), 1042. https://doi.org/10.2466/PMS.89.7.1042-1042

60.

Madubata

I. J.

Odafe

M. O.

Talavera

D. C.

Hong

J. H.

Walker

R. L.

(2018). Helplessness mediates racial discrimination and depression for African American young adults. Journal of Black Psychology, 44(7), 626-643. https://doi.org/10.1177/0095798418811476

61.

Marco

J. H.

Pérez

García-Alandete

(2016). Meaning in life buffers the association between risk factors for suicide and hopelessness in participants with mental disorders. Journal of Clinical Psychology, 72(7), 689-700. https://doi.org/10.1002/jclp.22285

62.

McGirr

Renaud

Bureau

Seguin

Lesage

Turecki

(2008). Impulsive-aggressive behaviours and completed suicide across the life cycle: A predisposition for younger age of suicide. Psychological Medicine, 38(3), 407-417. https://doi.org/10.1017/S0033291707001419

63.

Morrison

L. L.

Downey

D. L.

(2000). Racial differences in self-disclosure of suicidal ideation and reasons for living: Implications for training. Cultural Diversity and Ethnic Minority Psychology, 6(4), 374-386. https://doi.org/10.1037/1099-9809.6.4.374

64.

Morrison

K. S.

Hopkins

(2019). Cultural identity, Africultural coping strategies, and depression as predictors of suicidal ideations and attempts among African American female college students. Journal of Black psychology, 45(1), 3-25. https://doi.org/10.1177/0095798418813511

65.

Neblett

E. W.

Banks

K. H.

Cooper

S. M.

Smalls-Glover

(2013). Racial identity mediates the association between ethnic-racial socialization and depressive symptoms. Cultural Diversity and Ethnic Minority Psychology, 19(2), 200-207. https://doi.org/10.1037/a0032205

66.

Nrugham

Holen

Sund

A. M.

(2012). Suicide attempters and repeaters. Journal of Nervous & Mental Disease, 200(3), 197-203. https://doi.org/10.1097/NMD.0b013e318247c914

67.

Osman

Kopper

B. A.

Linehan

M. M.

Barrios

F. X.

Gutierrez

P. M.

Bagge

C. L.

(1999). Validation of the adult suicidal ideation questionnaire and the reasons for living inventory in an adult psychiatric inpatient sample. Psychological Assessment, 11(2), 115. https://doi.org/10.1037/1040-3590.11.2.115

68.

Palmer

C. J.

(2001). African Americans, depression, and suicide risk. Journal of Black Psychology, 27(1), 100-111. https://doi.org/10.1177/0095798401027001006

69.

Perez-Rodriguez

Baca-Garcia

Oquendo

Blanco

(2008). Ethnic differences in suicidal ideation and attempts. Primary Psychiatry, 15(2), 44-53.

70.

Phinney

J. S.

(1990). Ethnic identity in adolescents and adults: Review of research. Psychological Bulletin, 108, 499-514. https://doi.org/10.1037/0033-2909.108.3.499

71.

Polanco-Roman

Miranda

(2013). Culturally related stress, hopelessness, and vulnerability to depressive symptoms and suicidal ideation in emerging adulthood. Behavior Therapy, 44(1), 75-87. https://doi.org/10.1016/j.beth.2012.07.002

72.

Preacher

K. J.

Hayes

A. F.

(2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40(3), 879-891. https://doi.org/10.3758/BRM.40.3.879

73.

Qiu

Klonsky

E. D.

Klein

D. N.

(2017). Hopelessness predicts suicide ideation but not attempts: A 10-year longitudinal study. Suicide and Life-Threatening Behavior, 47(6), 718-722. https://doi.org/10.1111/sltb.12328

74.

Reynolds

W. M.

(1991). Psychometric characteristics of the adult suicidal ideation questionnaire in college students. Journal of Personality Assessment, 56(2), 289-307. https://doi.org/10.1207/s15327752jpa5602_9

75.

Reynolds

J. E.

Gonzales-Backen

M. A.

(2017). Ethnic-racial socialization and the mental health of African Americans: A critical review. Journal of Family Theory & Review, 9(2), 182-200. https://doi.org/10.1111/jftr.12192

76.

Ribeiro

J. D.

Huang

Fox

K. R.

Franklin

J. C.

(2018). Depression and hopelessness as risk factors for suicide ideation, attempts and death: meta-analysis of longitudinal studies. British Journal of Psychiatry, 212(5), 279-286. https://doi.org/10.1192/bjp.2018.27

77.

Ryff

C. D.

(1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57(6), 1069-1081. https://dx-doi-org.web.bisu.edu.cn/10.1037/0022-3514.57.6.1069

78.

Ryff

C. D.

(2014). Psychological well-being revisited: Advances in the science and practice of eudaimonia. Psychotherapy and Psychosomatics, 83(1), 10-28. https://doi.org/10.1159/000353263

79.

Ryff

C. D.

Keyes

C. L. M.

(1995). The structure of psychological well-being revisited. Journal of Personality and Social Psychology, 69(4), 719-727. https://doi.org/10.1037/0022-3514.69.4.719

80.

Segal

D. L.

Coolidge

F. L.

Cahill

B. S.

O'Riley

A. A.

(2008). Psychometric properties of the beck depression inventory-II (BDI-II) among community-dwelling older adults. Behavior Modification, 32(1), 3-20. https://doi.org/10.1177/0145445507303833

81.

Segal

Z. V.

Williams

J. M. G.

Teasdale

J. D.

(2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Guilford Press.

82.

Sibinga

E. M. S.

Kerrigan

Stewart

Johnson

Magyari

Ellen

J. M.

(2011). Mindfulness-based stress reduction for Urban youth. The Journal of Alternative and Complementary Medicine, 17(3), 213-218. https://doi.org/10.1089/acm.2009.0605

83.

Silenzio

V. M. B.

Pena

J. B.

Duberstein

P. R.

Cerel

Knox

K. L.

(2007). Sexual orientation and risk factors for suicidal ideation and suicide attempts among adolescents and young adults. American Journal of Public Health, 97(11), 2017-2019. https://doi.org/10.2105/AJPH.2006.095943

84.

Steeg

Haigh

Webb

R. T.

Kapur

Awenat

Gooding

Pratt

Cooper

(2016). The exacerbating influence of hopelessness on other known risk factors for repeat self-harm and suicide. Journal of Affective Disorders, 190, 522-528. https://doi.org/10.1016/j.jad.2015.09.050

85.

Steger

M. F.

Frazier

(2005). Meaning in life: One link in the chain from religiousness to well-being. Journal of Counseling Psychology, 52(4), 574-582. https://doi.org/10.1037/0022-0167.52.4.574

86.

Taylor

Turner

R. J.

(2002). Perceived discrimination, social stress, and depression in the transition to adulthood: Racial contrasts. Social Psychology Quarterly, 65(3), 213-225. https://doi.org/10.2307/3090120

87.

Thompson

V. L. S.

(2006). African American body image: Identity and physical self-acceptance. Humboldt Journal of Social Relations, 30(2), 44-67.

88.

Thompson

M. P.

Kaslow

N. J.

Kingree

J. B.

(2002). Risk factors for suicide attempts among African American women experiencing recent intimate partner violence. Violence and Victims, 17(3), 283-295. https://doi.org/10.1891/vivi.17.3.283.33658

89.

Van Orden

K. A.

Witte

T. K.

Cukrowicz

K. C.

Braithwaite

S. R.

Selby

E. A.

Joiner

T. E.

Jr. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575-600. https://doi.org/10.1037/a0018697

90.

Verona

Sachs-Ericsson

Joiner

T. E.

(2004). Suicide attempts associated with externalizing psychopathology in an epidemiological sample. American Journal of Psychiatry, 161(3), 444-451. https://doi.org/10.1176/appi.ajp.161.3.444

91.

Walker

R. L.

Ashby

Hoskins

O. D.

Greene

F. N.

(2009). Peer-support suicide prevention in a non-metropolitan U.S. community. Adolescence, 44(174), 335-346.

92.

Walker

Francis

Brody

Simons

Cutrona

Gibbons

(2017). A longitudinal study of racial discrimination and risk for death ideation in African American youth. Suicide and Life-Threatening Behavior, 47(1), 86-102. https://doi.org/10.1111/sltb.12251

93.

Walker

R. L.

Salami

T. K.

Carter

S. E.

Flowers

(2014). Perceived racism and suicide ideation: Mediating role of depression but moderating role of religiosity among African American adults. Suicide and Life-Threatening Behavior, 44(5), 548-559. https://doi.org/10.1111/sltb.12089

94.

Walker

R. L.

Wingate

L. R.

Obasi

E. M.

Joiner

T. E.

(2008). An empirical investigation of acculturative stress and ethnic identity as moderators for depression and suicidal ideation in college students. Cultural Diversity and Ethnic Minority Psychology, 14(1), 75-82. https://doi.org/10.1037/1099-9809.14.1.75

95.

Wang

M.-C.

Joel Wong

Tran

K. K.

Nyutu

P. N.

Spears

(2013). Reasons for living, social support, and afrocentric worldview: Assessing buffering factors related to Black Americans’ suicidal behavior. Archives of Suicide Research, 17(2), 136-147. https://doi.org/10.1080/13811118.2013.776454

96.

Wang

M.-C.

Lightsey

O. R.

Tran

K. K.

Bonaparte

T. S.

(2013). Examining suicide protective factors among black college students. Death Studies, 37(3), 228-247. https://doi.org/10.1080/07481187.2011.623215

97.

Watkins

D. C.

Assari

Johnson-Lawrence

(2015). Race and ethnic group differences in comorbid major depressive disorder, generalized anxiety disorder, and chronic medical conditions. Journal of Racial and Ethnic Health Disparities, 2(3), 385-394. https://doi.org/10.1007/s40615-015-0085-z

98.

Wetherall

Cleare

Eschle

Ferguson

O'Connor

D. B.

O'Carroll

R. E.

O'Connor

R. C.

(2018). From ideation to action: differentiating between those who think about suicide and those who attempt suicide in a national study of young adults. Journal of Affective Disorders, 241, 475-483. https://doi.org/10.1016/j.jad.2018.07.074

99.

Williams

M. T.

Chapman

L. K.

Wong

Turkheimer

(2012). The role of ethnic identity in symptoms of anxiety and depression in African Americans. Psychiatry Research, 199(1), 31-36. https://doi.org/10.1016/j.psychres.2012.03.049

100.

Woods-Giscombé

C. L.

Black

A. R.

(2010). Mind-body interventions to reduce risk for health disparities related to stress and strength among African American women: The potential of mindfulness-based stress reduction, loving-kindness, and the NTU therapeutic framework. Complementary Health Practice Review, 15(3), 115-131. https://doi.org/10.1177/1533210110386776

101.

Woods-Giscombé

C. L.

Gaylord

S. A.

(2014). The cultural relevance of mindfulness meditation as a health intervention for African Americans. Journal of Holistic Nursing, 32(3), 147-160. https://doi.org/10.1177/0898010113519010

102.

Yoon

Coburn

Spence

S. A.

(2019). Perceived discrimination and mental health among older African Americans: The role of psychological well-being. Aging & Mental Health, 23(4), 461-469. https://doi.org/10.1080/13607863.2017.1423034

103.

Zhang

Carr

E. R.

Garcia-Williams

A. G.

Siegelman

A. E.

Berke

Niles-Carnes

L. V.

Patterson

Watson-Singleton

N. N.

Kaslow

N. J.

(2018). Shame and depressive symptoms: Self-compassion and contingent self-worth as mediators? Journal of Clinical Psychology in Medical Settings, 25(4), 408-419. https://doi.org/10.1007/s10880-018-9548-9

104.

Zhang

Watson-Singleton

N. N.

Pollard

S. E.

Pittman

D. M.

Lamis

D. A.

Fischer

N. L.

Patterson

Kaslow

N. J.

(2019). Self-criticism and depressive symptoms: Mediating role of self-compassion. OMEGA - Journal of Death and Dying, 80(2), 202-223. https://doi.org/10.1177/0030222817729609