Experience of Being Bullied, Depressive Symptoms, Suicidality, and Substance Use among Adolescents

Background: Depressive symptoms, suicidality, and the experience of having been bullied are prevalent among adolescents in the United States. In addition, substance use is also common among adolescents in the United States. Both the experience of depressive symptoms and suicidality and of having been bullied have been associated with substance use. However, the context in which these adolescent experiences and behaviors are occurring are changing (e.g., changing state-level cannabis laws, the advent of electronic vapor products, increased use of social media, and the COVID-19 pandemic), warranting updated, comprehensive investigations in this area. Objectives: We aimed to 1) determine if depressive symptoms and suicidality are associated with current use of alcohol, electronic vapor products, cannabis, and prescription pain medicine among adolescents; 2) determine if the associations of depressive symptoms and suicidality with use of alcohol, electronic vapor products, cannabis, and prescription pain medicine have changed over time in adolescents; 3) determine if the experience of being bullied electronically or at school is associated with the current use of alcohol, electronic vapor products, cannabis, and prescription pain medicine among adolescents; and 4) describe the impact of COVID-19 on adolescent-reported substance use, social media use, and depressive symptoms. Methods: We utilized 2019 Youth Risk Behavior Study (YRBS) data to assess cross-sectional associations of the experience of having been bullied, depressive symptoms, and suicidality with substance use and YRBS data from 1991 to 2019 to assess for changes in cross-sectional associations of depressive symptoms and suicidality with substance use over time. We applied appropriate survey weights and utilized multivariable logistic regression to model associations between past 12 month depressive symptoms and suicidality indicators (considering suicide, suicide plans, suicide attempts, and injurious suicide attempts) as independent variables in Aims 1 and 2, past 12 month experience of being bullied electronically and at school as independent variables in Aim 3, and past 30 day ever use of substances (cannabis use, alcohol use, binge drinking, electronic vapor product use, or prescription pain medicine misuse) as dependent variables in Aims 1, 2, and 3. Due to lack of time points for which data on past 30 day prescription pain medicine was available, we additionally considered lifetime prescription pain medicine misuse as a dependent variable in Aim 2. We presented odds ratios (ORs), adjusted ORs (aORs), and corresponding 95% confidence intervals (CIs) for unadjusted, partially adjusted (including covariates for sex, racial/ethnic identity, sexual identity, and age), and fully adjusted (additionally including other substance use) models. To assess the impact of the COVID-19 pandemic (Aim 4), we conducted a scoping review and a survey-based study. For the scoping review, we utilized Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines and searched PubMed, PsycINFO, and Embase. Inclusion criteria were quantitative or qualitative studies among 12 to 17 year-olds or their caregivers and provided results that were specific to adolescents (age 10 to 19 years or middle school to high school) in the United States and data collected at least at one time point since March 1, 2020 (reflecting the beginning of the impact of the pandemic on daily life for the public). For the survey-based study, we conducted an anonymous, REDCap-based online survey of adolescents (ages 13 to 19 years) in the United States assessing retrospective reports of social media use, substance, and depressive symptoms in April 2019, April 2020, and April 2021. We summarized participant responses with frequencies and percentages and assessed for differences over time with Fisher’s exact tests. Results: In weighted analyses of 2019 YRBS participants, 36.2% of participants reported depressive symptoms in the past 12 months and 30.9% of participants reported any use of electronic vapor products in the past 30 days. We found that depressive symptoms in the past 12 months were statistically significantly associated with ever past 30 day alcohol use (aOR: 1.28; 95% CI: 1.09, 1.51; p = 0.004), ever past 30 day cannabis use (aOR: 1.43; 95% CI: 1.20, 1.70; p < 0.001), ever past 30 day electronic vapor product use (aOR: 1.55; 95% CI: 1.30, 1.84; p < 0.001), and ever past 30 day prescription pain medicine misuse (aOR: 2.62; 95% CI: 1.97, 3.48; p < 0.001) except for ever past 30 day binge drinking (aOR: 1.42; 95% CI: 1.02, 1.99; p = 0.041) in fully adjusted models including demographics and other substance use. Significant positive associations were also observed for suicidality indicators. In assessment for changes in these associations over time, for all past 12 month depressive symptom and suicidality indicators, associations with past 30 day ever use of alcohol and cannabis have increased slightly over time. Assessments of time trends of associations for past 30 day binge drinking, past 30 day electronic vapor product use, and lifetime prescription pain medicine misuse were limited by few available time points, but these associations remained relatively stable over assessed time points. Assessing associations of having been bullied and substance use with 2019 YRBS data, we found significant associations of being bullied at school and electronically in the past 12 months with any past 30 day use of electronic vapor products (school: aOR: 1.49; 95% CI: 1.21, 1.84; p < 0.001; electronic: aOR: 1.89; 95% CI: 1.55, 2.31; p < 0.001) and prescription pain medicine misuse (school: aOR: 2.10; 95% CI: 1.72, 2.55; p < 0.001; electronic: aOR: 1.99; 95% CI: 1.48, 2.67; p < 0.001) after full adjustment. Fully adjusted associations were not statistically significant for past 12 month alcohol use, binge drinking, or prescription pain medicine misuse, but significant in most partially adjusted models excluding use of other substances as a covariate. In our scoping review, we identified 29 relevant studies (social media use n = 7; substance use n = 4; depressive symptoms n = 22). Though we observed a variety of methods of measuring depressive symptoms, cross-sectional assessments indicated a high prevalence of depressive symptoms during the pandemic, but longitudinal trajectories suggested a possible decrease in the first few months after the onset of the pandemic. High social media use was reported and two studies suggested lower e-cigarette use during the pandemic. In our survey-based study, we observed a statistically significant increase in reported social media use over time (p = 0.04) in participants reporting using social media at least once a day in April 2019 (70.4%), April 2020 (81.5%), and April 2021 (88.9%). We also observed increases, though not statistically significantly different, across years in substance use (April 2019: cannabis: 11.1%, electronic vapor product use: 7.4%, alcohol use: 7.4%, binge drinking: 7.4%, prescription pain medicine misuse: 0%; April 2021: cannabis: 18.5%, electronic vapor product use: 25.9%, alcohol use: 14.8%, binge drinking: 11.1%, prescription pain medicine misuse: 7.4%) and depressive symptoms (April 2019: 48.1;, April 2020: 70.4%; April 2021: 66.7%). Conclusion and Discussion: We identified evidence for positive associations of the experience of having been bullied, depressive symptoms, and suicidality with substance use in a recent, representative sample of adolescents. Further, the associations of depressive symptoms and suicidality with alcohol use and cannabis use may have increased slightly over time. The COVID-19 pandemic may be associated with greater social media use and increased depressive symptoms. Adults with prominent roles in adolescent lives should aim to teach and encourage healthy coping skills. Further, they should be aware that adolescents who experience being bullied or depressive symptoms may be more likely to engage in substance use, and vice versa. In the face of the COVID-19 pandemic, adolescents may require additional mental health support. Future research directions include longitudinal studies to elucidate directionality of associations, studies with diverse participants to comprehensively assess the potential moderating role of identity factors, and ongoing monitoring of the present and future impacts of the COVID-19 pandemic. Sources of Support and Acknowledgements: This work was supported in part by a student project stipend from the Northwest Public Health Training Center at the Northwest Center for Public Health Practice (sponsored by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) (grant # 6 UB6HP31690-04-01)) and by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant #T76MC00011. REDCap at ITHS is supported by the National Center For Advancing Translational Sciences of the National Institutes of Health under Award Number UL1 TR002319. Ruchi Tiwari was the second reviewer for this scoping review.