Introduction

Bereavement refers to a significant life event in which an individual experiences the death of a close friend or family member. This experience can trigger severe psychological and physiological reactions, with particularly pronounced effects in adolescent populations1. Adolescents are at a critical stage of physical and psychological development, during which their emotional regulation, coping abilities, and social support systems are not yet fully matured2. Therefore, the death of a loved one may have a profound impact on their psychological well-being. A substantial body of research indicates that bereaved adolescents are more prone to negative psychological states such as depression and anxiety, often accompanied by academic difficulties and impaired interpersonal relationships3. Moreover, bereavement is considered a significant risk factor for suicidal ideation among adolescents4,5. Adolescents who have lost a loved one may experience an increased risk of suicide due to negative emotions such as grief, guilt, and helplessness6. Some individuals may also be influenced by the imitation effect, wherein the suicide or death of a loved one increases their own risk of suicide7.

According to the Integrated Motivational-Volitional (IMV) model of suicide, the formation of suicidal ideation primarily emerges during the transition from the “pre-motivational” phase to the “motivational” phase8. In the specific stress context of bereavement, adolescents encounter intense emotional disruption and life changes. This experience of loss often elicits a profound sense of “defeat,” where adolescents feel unable to cope with the pain brought by bereavement9. When this sense of defeat combines with the individual’s perceived subjective experience of being “unable to escape,” it gives rise to the core psychological state predicting suicidal ideation in the Integrated Motivational–Volitional model: the sense of “entrapment.” Moreover, the transition from a sense of entrapment to suicidal ideation does not occur inevitably; it is moderated by specific “motivational moderator variables.” Among bereaved adolescents, risk factors such as hopelessness, psychological distress, and levels of depression serve as critical moderator variables, significantly increasing the likelihood that a sense of entrapment will translate into suicidal ideation10. Therefore, from the perspective of the Integrated Motivational–Volitional model, this study aims to investigate how these specific risk factors trigger or exacerbate suicidal ideation among bereaved adolescents.

In recent years, research on post-bereavement suicidal ideation among adolescents in Eastern countries has gradually increased, but overall remains limited. Most studies have primarily focused on the broad psychological impacts of bereavement, such as depression and anxiety. While lacking a systematic analysis of specific risk factors for suicidal ideation among bereaved adolescents11,12. Although previous studies have examined risk factors for suicidal ideation among adolescents who actively seek help from mental health hotlines. However, research specifically targeting bereaved adolescents, a high-risk population, remains very limited. Existing studies have not fully utilized real-time psychological state data of adolescents following bereavement. As a result, it is difficult to clearly identify the high-risk characteristics and potential risk factors of their suicidal ideation. In contrast, although studies in Western countries employ more systematic variable measurements. their conclusions remain uncertain in terms of applicability to adolescent populations in Eastern countries13. Based on the aforementioned research gap, this study utilizes cross-sectional data from China’s largest psychological support hotline. Within the Chinese cultural context, it systematically investigates the potential risk factors for suicidal ideation among bereaved adolescents who actively seek psychological assistance, and analyzes the possible interactive mechanisms of these factors. This approach aims to elucidate the risk characteristics associated with elevated suicidal ideation in bereaved adolescents.

The psychological support hotline is a crucial channel for adolescents seeking psychological support, offering immediate, anonymous, and professional assistance. Hotline data can reflect adolescents’ psychological characteristics and help-seeking behaviors in times of crisis14. Therefore, this study, based on the actual circumstances of hotline callers, provides a more accurate reflection of the psychological distress and suicide risk among bereaved adolescents. Specifically, the objectives of this study include: (1) To investigate the prevalence of suicidal ideation among bereaved adolescents, in order to reveal the current suicide risk status of this group. (2) To explore the risk factors influencing suicidal ideation among bereaved adolescents. The significance of this study lies in filling the research gap in this field and providing empirical support for the development of psychological intervention strategies for bereaved adolescents. Additionally, the findings of this study can provide a theoretical basis for optimizing the services of the psychological support hotline, enabling more effective identification and intervention for high-risk individuals, thereby reducing the incidence of adolescent suicide.

Materials and methods

Sample

The Beijing psychological support hotline is the largest psychological support hotline in China, with one of its core functions being the provision of crisis intervention services. The psychological support hotline provides psychological support and intervention to tens of thousands of help-seekers annually, with particular attention to the mental health needs of individuals at high risk for suicide. The hotline operators possess professional backgrounds in psychology or psychiatry and have received systematic training in suicide prevention and intervention. They are proficient in the procedures and assessment systems of the psychological support hotline and are capable of promptly collecting and reporting critical information. In addition, the hotline operators are equipped to handle calls from adolescents at high risk of suicide, ensuring the provision of effective psychological support and intervention in crisis situations.

The Beijing psychological support hotline has established a comprehensive assessment system to ensure the delivery of systematic and professional psychological support to every caller. This assessment system has been widely implemented across psychological support hotlines throughout China and has been validated by numerous studies15. Each call is associated with a detailed case record, in which the hotline operator is required to document the caller’s basic demographic information and conduct a comprehensive assessment of their psychological state and suicide risk factors. The assessment covers the intensity of suicidal ideation, history of suicide attempts, level of psychological distress, severity of depression, feelings of helplessness, and common suicide risk factors. The entire assessment process typically lasts about 30 min.

This study includes all calls received by the Beijing psychological support hotline between July 2022 and June 2024. The exclusion criteria are as follows: (1) Calls from individuals who are not adolescents. (2) Calls from individuals who are not bereaved. (3) Calls with a duration of less than 600 s. (4) Silent calls, harassing calls, hang-up calls, and calls requesting only general information.

This study included a total of 850 bereaved adolescents aged 12–18 years. Among them, 754 callers (88.7%) reported experiencing suicidal ideation within the past two weeks, while 96 callers (11.3%) did not. There were 558 female callers (65.6%) and 292 male callers (34.4%). The mean age of the participants was 15 ± 2 years, with 294 callers (34.6%) in the 12 to 14-year age group and 556 callers (65.4%) in the 15 to 18-year age group. Years of education: 0–6 years, 158 callers (18.6%); 7–9 years, 412 callers (48.5%); 10–15 years, 280 callers (32.9%).

Ethics approval and consent to participate

This study was approved by the Institutional Review Committee of Beijing Huilongguan Hospital (2022-12-Science). The committee explicitly authorized this study to waive parental informed consent under the principles of anonymity and data minimization. During the study, each adolescent caller was thoroughly informed prior to the hotline consultation that the content of the call would be used solely for research and supervision purposes, all information would be anonymized, and participation in the study was voluntary. Once the caller confirmed their informed understanding and chose to continue the call, it was considered as their consent to participate in the hotline consultation and the associated research, after which the consultation formally began. When approving the waiver of parental informed consent, the IRB explicitly considered the following factors to determine that the study posed minimal risk: callers were in a state of spontaneous help-seeking, and the consultation content involved mental health issues, such that requiring parental consent could hinder help-seeking or increase psychological burden; the study utilized fully anonymized hotline call records, with no collection of any information directly identifying individuals; and data processing adhered to the principle of data minimization, using only the information necessary for scientific analysis.

To ensure data security, multiple measures were implemented in this study. All call records were anonymized by removing names, phone numbers, and other identifiable information; data were stored on encrypted servers with restricted access, accessible only to authorized researchers; during analysis, callers were identified using coded numbers to prevent duplicate records from affecting the results, and duplicate calls were further excluded through cross-checking timestamps and self-reported characteristic information. This procedure complies with the exemption criteria for minimal-risk research outlined in the international ethical guidelines, the Declaration of Helsinki and the CIOMS Guidelines, while clearly documenting the minor consent process, data protection measures, and procedures for identifying and excluding duplicate calls.

Measures

This study employed the suicide risk assessment scale used by the psychological support hotline. The scale is designed to evaluate the caller’s emotional state, suicide risk, and basic psychological distress within a short period16,17. However, it does not include specific screening items for psychotic experiences, such as hallucinations, delusions, loosening of associations, or thought disorder. Therefore, this study was unable to obtain information on psychotic symptoms during the data collection phase, and these symptoms could not be included as exclusion criteria or covariates in the statistical analysis. At the beginning of the call, operators use the suicide risk assessment scale to systematically evaluate each caller’s level of suicide risk. The scale comprises 12 core items: suicidal ideation, severe depression, hopelessness, psychological distress, acute life events, chronic life events, alcohol or substance misuse, serious physical illness, fear of being attacked, history of being abuse, history of suicide attempts, and relatives or acquaintances suicidal acts history16. The scale demonstrated good reliability, with an intraclass correlation coefficient of 0.93 for the total score, and Cohen’s kappa values for the 12 items ranging from 0.54 to 0.9518. The following are the specific items of the 12 core components and their coding in the present study:

Suicidal ideation. (1) In the last two weeks, have you had thoughts of death or take your life? (2) In the last two weeks, have you felt exhausted, tired, meaningless, even would rather to die? (3) In the last two weeks, did you have any suicide plan (where, when, and method to conduct suicidal acts) or suicide attempt? Hotline operator evaluates caller’s degree of suicidal ideation and plan based on caller’s responses16. In this study, based on operators’ assessments and previous research coding methods19, the absence of suicidal ideation was coded as 0, and the presence of suicidal ideation was coded as 1.

Severe depression. This assessment was derived from the depression diagnostic screening scale20. The scale assesses the nine core symptoms of major depressive episodes based on the DSM-5 and calculates the product of the severity of each depressive symptom and its duration in the two weeks prior to the call. The total depression score is obtained by summing the scores of all symptoms, with a range from 0 to 100. A higher score indicates more severe depressive symptoms.

Hopelessness. “To what extent do you feel hopeful now? A score of 100 indicates very hopeful, while 0 indicates completely hopeless.” In this study, hopelessness was categorized into three groups based on (P25, P75): ≤0 as severe hopelessness, > 0 and < 50 as moderate hopelessness, and ≥ 50 as mild hopelessness21.

Psychological distress. “To what extent do you feel psychological distress now? A score of 100 indicates very severe psychological distress, while 0 indicates no psychological distress at all.” In this study, psychological pain was categorized into three groups based on (P25, P75): ≤70 as low pain, > 70 and < 96 as moderate pain, and ≥ 96 as high distress21.

Acute life events16. (1) In last week, whether one or more negative life events occurred and substantially impact on your mental health? If yes, then (2) To what extent (no, mild, moderate, severe, or enormous) the impacts were while the life event occurred? 0 was coded as no acute life events in the last week, or events with no or mild impact; 1 was coded as yes, with moderate, severe, or enormous impact.

Chronic life events16. (1) Did any family, work, or other problems exist and adversely impact on your mental health in long-term? If yes, then (2) In the last month, to what extent (no, mild, moderate, severe, or enormous) the impacts have been. 0 was coded as no chronic life events, or events with no or mild impact; 1 was coded as yes, with moderate, severe, or enormous impact.

Alcohol or substance misuse16. (1) In the last 12 months, have you ever been excessive drinking or drunk at least 4 times, resulting in study or work difficulties, interpersonal, mental or physical problems? (2) In the last 12 months, have you taken narcotic drugs, or excessively or rashly taken hypnotics, sedatives, anxiolytics, anesthetics, or stimulants at least in consecutive 3 month? If yes to any of the 2 questions, then (3) To what extent (no, mildly, moderately, severely, enormously) you have been distressed or disturbed, or your daily life, social activity, or work/study performance have been impacted, by the alcohol/substance misuse? 0 was coded as no alcohol or substance misuse, or misuse with no or only mild impact; 1 was coded as having alcohol or substance misuse with moderate, severe, or enormous impact.

Severe physical illness16. Whether your life has been severely impacted by physical illness or disability till now? 0 was coded as no; 1 was coded as yes.

Fear of being attacked16. (1) Have you often feared being attacked by someone else in the last month? If yes, then (2) To what extent (no, mild, moderate, severe, or enormous) the fear impacted you. 0 was coded as no fears or fear with no or mild impact; 1 was coded as fear with moderate, severe, or enormous impact.

History of being abused16. (1) Have you ever been physically or sexually abused? If yes, then (2) To what extent (no, mild, moderate, severe, or enormous) such experiences impact you in the last month? 0 was coded as no history of abuse, or abuse with no or mild impact; 1 was coded as having been abused with moderate, severe, or enormous impact.

Suicide attempt history16. Whether you made one or more suicide attempts prior to the last 2 weeks? 0 was coded as never; 1 was coded as at least once.

Relatives or acquaintances suicidal acts history16. (1) How many your blood relatives had history of suicidal acts (attempts or death)? (2) How many your non-blood relatives or other acquaintances had history of suicidal acts (attempt or death)? 0 was coded as none, for either relatives or acquaintances; 1 was coded as at least one relative or acquaintance having a history of suicidal acts.

The assessment of grief reactions is based on the diagnostic criteria for complicated grief in the DSM-5 and is incorporated into the psychological support hotline assessment system22. The assessment includes 7 items: (1) Repeatedly thinking about or wanting to visit places related to him/she. (2) Feeling pain when thinking about him or avoiding scenes related to him/she. (3) Feeling lonely or numb. (4) Not accepting the reality of death. (5) Hearing his voice or seeing him/she. (6) Feeling unfairness, anger, or rage about his death. (7) Isolating from others or experiencing a reduced sense of trust in others11. Callers responded with “yes” or “no,” with “yes” scored as 1 and “no” scored as 0. A higher score indicates a higher level of grief response in the caller. The KR-20 coefficient of the scale in this study was 0.938.

This study also collected bereavement-related information through interviews. The data were gathered primarily by asking “When did he/she pass away?” and “What was your relationship with the deceased?” to obtain information on the caller’s relationship with the deceased and the time elapsed since the death23. In addition, general demographic information was collected, including gender, age, years of education, and history of previous diagnoses.

The data for this study were collected by uniformly trained operators through one-on-one standardized interviews. To further ensure data quality, interviews lasting less than 600 s were excluded to minimize perfunctory or incomplete responses due to insufficient interview duration. During the interview, operators provided immediate clarification if ambiguous or contradictory responses occurred. Simultaneously, the system recorded response times and other information in real time to identify clearly abnormal answering behaviors. Finally, we conducted logical consistency checks on key variables and excluded samples with unreasonable combinations. These measures ensured the accuracy and reliability of the samples included in the final analysis.

Statistical analysis

The sample size was estimated using G*Power 3.1. The test was set as a comparison of two independent sample proportions. Based on previous literature comparing hotline callers with and without suicidal ideation24, P1 was set at 0.49 and P2 at 0.23, with a significance level α of 0.05 and statistical power (1–β) of 0.90. The minimum sample size per group was calculated to be 77 cases.

Statistical analyses were conducted using SPSS version 26.0 and R x64 version 4.5.2. We examined missingness for all variables in SPSS. First, the missing proportion for each variable was calculated. The overall missing rate was 1.33%, with the missing rates for individual variables as follows: hopelessness (4.7%), psychological distress (3.4%), Alcohol or substance misuse (1.4%), chronic events (2.4%), acute events (2.6%), physical illness (1.5%), history of being abused (2.9%), fear of being attacked (3.1%), and relatives or acquaintances suicidal acts history (3.3%). Next, we used Little’s MCAR test to examine whether the missing data were completely at random. The results (χ²=2.232, p = 0.328) indicated that the missing pattern was consistent with the assumption of completely random missingness. In this study, unanswered or invalid items in the scale were uniformly coded as 999 and designated as user-defined missing values in SPSS. In subsequent logistic regression analyses, SPSS automatically performed listwise deletion for missing data; thus, each analysis was conducted using only cases with valid data for the variables included.

SPSS version 26.0 was used for descriptive analyses, independent-samples t tests, chi-square tests, binary logistic regression, and multiplicative interaction analyses. The severity of depression and grief followed a normal distribution and were expressed as (mean ± standard deviation). Other data were presented as frequencies and percentages (%). Differences in depression and grief levels between adolescents with and without suicidal ideation were examined using independent-samples t tests, and Cohen’s d was calculated as the effect size (Cohen’s d values of 0.20, 0.50, and 0.80 were interpreted as small, medium, and large effect sizes, respectively)25. Chi-square tests were used to compare bereavement-related information, demographic characteristics, and suicide-related factors between adolescents with and without suicidal ideation. When any cell count was less than 5, Fisher’s exact test was applied, and Cramer’s V was calculated as the effect size (Cramer’s V values of 0.10, 0.30, and 0.50 were interpreted as small, medium, and large effect sizes, respectively)26. Binary logistic regression was used to examine the risk factors for suicidal ideation, with regression coefficients, odds ratios (OR), and their 95% CIs reported. A p-value < 0.05 was considered statistically significant. The interaction effect of risk factors was tested by entering their product terms into the binary logistic regression, with p < 0.05 indicating a significant interaction between the two factors. The significance level was set at α = 0.05, with two-tailed tests.

R x64 version 4.5.2 was used to analyze additive interaction. First, missing data were imputed using the mice package in R, with the logistic regression (logreg) method. For analyses in which all exposures were binary, 95% confidence intervals were estimated using the delta method27, and additive interaction was evaluated using the interactionR package. For analyses involving continuous exposures only or a combination of continuous and binary exposures, we followed Knol’s method28. First, the continuous variables of depression severity and grief severity were scaled by 2 standard deviations (2-SD)29. The 2-SD values for depression severity and grief severity were 34.1 points and 3.62 points, respectively. Calculations were then performed using the formula proposed by Knol, with confidence intervals estimated via bootstrapping28. We implemented these formulas in R to estimate additive interaction for models with either two continuous exposures or one continuous and one binary exposure (see Supplementary Materials). Interaction was assessed using the relative excess risk due to interaction (RERI), the attributable proportion (AP), and the synergy index (SI). A positive additive interaction was indicated when RERI > 0, AP > 0, and SI > 1. A negative additive interaction was indicated when RERI < 0, AP < 0, and SI < 1. For statistical inference, additive interaction was considered statistically significant if the 95% confidence interval for RERI or AP excluded 0, or if the 95% confidence interval for SI excluded 127,28.

Results

Screening procedure for bereaved adolescents with and without suicidal ideation

A total of 54,511 calls were answered between July 2022 and June 2024. After excluding invalid calls, 47,650 calls remained; after further excluding calls seeking only other types of information, 45,054 calls related to personal issues remained. Among the calls related to personal issues, 3357 were identified as bereavement-related; after excluding duplicate calls, 2899 unique cases remained. Finally, after further screening, 850 bereavement-related calls were identified as involving adolescents. Of these, 754 calls were related to suicidal ideation, whereas 96 calls did not indicate any such ideation. See Fig. 1.

Fig. 1
Fig. 1
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Flowchart of enrolling and screening callers.

A comparison of bereavement-related characteristics between adolescents with and without suicidal ideation

In this study, no statistically significant difference was found between bereaved adolescents with and without suicidal ideation in relation to their relationship with the deceased. See Table 1.

Table 1 Comparison of grief data of bereaved adolescents with and without suicidal ideation.
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A comparison of demographic characteristics and suicide-related factors between adolescents with and without suicidal ideation

Independent-samples t tests showed that participants with suicidal ideation had higher depression severity (t = − 7.21, P < 0.001; Cohen’s d = 0.89) and grief severity (t = − 4.85, P < 0.001; Cohen’s d = 0.59) than those without suicidal ideation. Specifically, the effect size for depression was large (Cohen’s d = 0.89), whereas the effect size for grief was moderate (Cohen’s d = 0.59). This indicates a large between-group difference in depression severity and a moderate between-group difference in grief severity. See Table 2.

Table 2 Comparison of demographic data and suicide-related factors in bereaved adolescents with and without suicidal ideation.
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Chi-square tests showed that, compared with callers without suicidal ideation, callers with suicidal ideation more frequently reported fewer years of education (χ²=25.75, P < 0.001; Cramér’s V = 0.17), a history of suicide attempts (χ²=35.95, P < 0.001; Cramér’s V = 0.21), alcohol or substance misuse (χ²=10.29, P = 0.002; Cramér’s V = 0.10), chronic life events (χ²=4.03, P = 0.045; Cramér’s V = 0.07), fear of being attacked (χ²=4.29, P = 0.038; Cramér’s V = 0.07), hopelessness(χ²=29.82, P < 0.001; Cramér’s V = 0.19), and psychological distress (χ²=25.30, P < 0.001; Cramér’s V = 0.18). The effect sizes for years of education (Cramér’s V = 0.17), history of suicide attempts (Cramér’s V = 0.21), hopelessness (Cramér’s V = 0.19), and psychological distress (Cramér’s V = 0.18) were generally in the small-to-moderate range. In contrast, the effect size for alcohol or substance misuse (Cramér’s V = 0.10) was small, and the effect sizes for chronic life events (Cramér’s V = 0.07) and fear of being attacked (Cramér’s V = 0.07) were even smaller, indicating that although these factors were statistically significant, the between-group differences were limited in magnitude.

A multivariate logistic regression analysis of risk factors for suicidal ideation among bereaved adolescents

The presence or absence of suicidal ideation in bereaved adolescents (0 = no, 1 = yes) was used as the dependent variable, and general demographic data along with suicide-related factors were used as independent variables in a binary logistic regression analysis. see variable assignments in Table 3.

Table 3 Variable coding for the multivariate logistic regression analysis of risk factors for suicidal ideation among bereaved adolescents.
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The results indicated that, among bereaved adolescents, severe hopelessness (OR = 2.98; 95%CI, 1.16–7.66), severe psychological distress (OR = 3.91; 95%CI, 1.43–10.68), depression severity (OR = 1.03; 95% CI, 1.01–1.04), grief severity (OR = 1.17; 95% CI, 1.02–1.35), and a history of suicide attempts (OR = 2.01; 95%CI, 1.18–3.44) were associated with higher likelihood of reporting suicidal ideation. See Table 4.

Table 4 Logistic regression analysis of suicide ideation risk factors in bereaved adolescents.
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Multiplicative interaction effects of risk factors for suicidal ideation among bereaved adolescents

In this study, both psychological pain and hopelessness were initially categorized into three levels: severe, moderate, and mild. To enhance the robustness and interpretability of the statistical analysis, we optimized the grouping method based on the results of the binary logistic regression. Preliminary analysis indicated that the “severe” levels of both variables were significantly associated with suicidal ideation, whereas the risk differences between “moderate” and “mild” levels were minimal and not statistically significant. To reduce sparse data issues caused by excessive categories, enhance model stability, and ensure that subsequent interaction tests conform to epidemiological analysis standards. In this study, the “moderate” and “mild” levels were combined into a single “moderate-mild” category, the “severe” level was retained, and both variables were converted into binary variables (0 = moderate-mild, 1 = severe).

Models 1 to 10 represent the interaction effects between two factors in a multiplicative manner. The results indicated that no multiplicative interactions occurred among the factors. See Table 5.

Table 5 Multiplicative interaction analysis of suicide ideation risk factors in bereaved adolescents.
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Additive interaction effects of risk factors for suicidal ideation among bereaved adolescents

Models 11–20 represented the additive interaction between two factors. See Table 6. Model 19 showed a positive additive interaction between depression and a history of suicide attempts. The RERI = 2.66(95%CI: 0.23–10.36), AP = 0.42(95%CI: 0.09–0.57), and SI = 2.00(95%CI: 1.16–2.94). This indicates that when depression increased by 2-SD (34.1 points) and a history of suicide attempts was present among bereaved adolescents, the joint effect of the two factors on suicidal ideation exceeded the simple sum of their independent effects. Approximately 42% of the excess effect could be attributed to the synergistic interaction between the two factors. Using adolescents with lower depression levels and no history of suicide attempts as the reference group, bereaved adolescents with a 2-SD (34.1 points) increase in depression and a history of suicide attempts were 6.32 times (95%CI: 1.90-21.06) more likely to report suicidal ideation than the reference group.

Table 6 Evaluation indices of additive interactions among risk factors for suicidal ideation in bereaved adolescents.
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Discussion

The results of this study indicate that among the hotline sample, the detection rate of suicidal ideation in adolescents following bereavement was markedly high, reaching 88.7%. In contrast, the overall detection rate of suicidal ideation among adolescents seeking help through the psychological support hotline is 77.9%30. This difference suggests that, in the context of hotline help-seeking, bereavement may be associated with a higher detection rate of suicidal ideation among adolescents. From a developmental psychology perspective, regulatory mechanisms and coping strategies in adolescence are still in the process of maturation. When confronted with major life events, adolescents may have difficulty mobilizing effective coping resources and are therefore more likely to adopt maladaptive coping strategies31. Compared with general stressors, bereavement is often accompanied by deeper emotional pain, making adolescents more prone to negative attributions and thereby more likely to experience suicidal ideation32,33.

Within the framework of the Integrated Motivational Volitional model of suicide, bereavement, as a major stressful life event, serves as a background triggering factor in the pre-motivational phase of the model8. According to the findings of the present study, the development of suicidal ideation among bereaved adolescents is primarily driven by negative psychological states operating within the motivational phase. Specifically, when hopelessness and psychological distress intensify among bereaved adolescents, they are more likely to develop negative expectations about the future and experience overwhelming distress in the context of bereavement, which reinforces feelings of entrapment and, in turn, increases the risk of suicidal ideation9. In addition, depression and grief severity emerged as risk factors, suggesting that persistent emotional distress may impair adolescents’ emotion regulation capacity and hinder recovery following bereavement. Thereby making adolescents more likely to enter pathways leading to the emergence of suicidal ideation. On the other hand, the association between a history of suicide attempts and suicidal ideation supports the role of the volitional phase. Prior suicidal behavior may lower the threshold for the transition from ideation to action, making individuals more likely to enter a high-risk enactment trajectory once suicidal thoughts emerge. Overall, the structure of risk factors identified in this study is consistent with the IMV model’s pathway hypothesis of “background stress–motivational generation–behavioral vulnerability,” providing support for the identification of suicide risk in the context of bereavement.

Results from independent-samples t tests indicated that the between-group effect sizes for depression severity and grief severity were relatively large. This finding indicates that the magnitude of differences in depression and grief severity was more pronounced between adolescents with and without suicidal ideation. In the psychological support hotline sample, depression and grief may have stronger discriminative value for differentiating individuals with suicidal ideation from those without. Therefore, in hotline practice, operators should prioritize the systematic assessment of depressive and grief-related emotions. In contrast, although alcohol or substance misuse, chronic life events, and fear of being attacked were statistically significant in chi-square tests, their effect sizes were relatively small. This indicates that the magnitude of between-group differences in the distribution of these factors was limited. Based on the current data, a more cautious interpretation is that these factors may reflect certain background risk characteristics, but are insufficient on their own to serve as a basis for risk stratification. In the hotline context, these factors should be considered within a multifactorial assessment framework and interpreted in conjunction with core emotional indicators showing larger effect sizes and other information obtained during hotline interactions, rather than being used in isolation based on a single background factor.

This study found that, among bereaved adolescents contacting the psychological support hotline, higher levels of hopelessness were associated with a greater likelihood of reporting suicidal ideation. This finding is consistent with previous studies and further supports the role of hopelessness in the suicidal risk among adolescents30,34. Bereavement often entails intense emotional shock and experiences of hopelessness; such hopelessness may coexist with post-bereavement grief and be associated with suicidal ideation35,36. When adolescents face bereavement, they must cope not only with the pain of losing a loved one but also with a series of complex psychological adjustment processes37. In the absence of effective support, some adolescents are more likely to become trapped in states of helplessness and hopelessness, which may provide a psychological context for the development of suicidal ideation.

Consistent with prior research, the present study indicates that high levels of psychological distress constitute a risk factor for suicidal ideation among bereaved adolescents. Psychological distress has important reference value in suicide risk assessment and is one of the effective predictors of suicidal ideation among callers to psychological support hotlines38. For adolescents, the death of a loved one may trigger intense feelings of distress, which encompass not only grief and mourning but also a sense of helplessness and a negative outlook on the future. When adolescents are unable to effectively alleviate such distress, negative emotions may accumulate, thereby increasing the risk of suicidal ideation31,39. High levels of distress may further erode adolescents’ coping resources, making them more prone to negative cognitions and even experiences of hopelessness when confronting bereavement40. In this context, bereaved adolescents seeking help from psychological support hotlines are also more likely to report suicidal ideation.

The results of this study suggest that depression severity may be one of the risk predictors of suicidal ideation among bereaved adolescents in the psychological support hotline sample. Existing empirical evidence has demonstrated a stable positive association between depressive symptoms and suicidal ideation, such that higher levels of depression are generally associated with a correspondingly increased risk of suicidal ideation41. For adolescents, bereavement may exacerbate depressive symptoms, leading to persistent low mood and loss of interest. When depressive symptoms are more severe, adolescents are more prone to catastrophic thinking patterns, which may increase the risk of suicidal ideation42,43. Therefore, during psychological interventions for bereaved adolescents through the hotline, special attention should be given to changes in depressive symptoms, and effective psychological support and intervention strategies should be implemented to reduce the risk of suicidal ideation.

This study revealed a significant association between the level of grief and suicidal ideation among bereaved adolescents in the hotline sample. Adolescents often experience grief reactions when they lose significant family members or friends, and such grief responses are both common and normal44. However, according to Worden’s task-based model of grief45, if individuals are unable to complete the tasks of mourning through effective coping strategies, what is initially a normative grief response may evolve into prolonged grief disorder46,47. Previous studies suggest that prolonged or complicated grief is associated with an increased risk of suicide48. In future suicide intervention efforts for bereaved adolescents using the hotline, special attention should be paid to the duration of their grief response, with an emphasis on active listening and companionship. When necessary, grief counseling should be provided to help adolescents regulate their grief emotions, reduce the risk of suicide ideation, and promote long-term mental health maintenance49.

Across numerous studies of psychological support hotlines, a history of suicide attempts has consistently been reported as an important factor associated with suicidal ideation38. Consistent with prior findings, this study also observed in the hotline sample of bereaved adolescents that individuals with a history of suicide attempts were more likely to report suicidal ideation. Under the impact of bereavement as a major life event, adolescents with a history of suicide attempts may face greater psychological crises50. The loss of a loved one may intensify negative emotions in these adolescents and may also trigger recollections of previous suicidal behaviors. It may also weaken psychological inhibition against suicidal behavior, thereby objectively increasing the likelihood that suicidal ideation is reactivated51,52. Therefore, in interventions targeting bereaved adolescents through the hotline, particular attention should be given to individuals with a history of suicide attempts. Their suicide risk should be promptly identified, and targeted psychological support and interventions should be provided.

The additive interaction analysis in the present study indicated an additive interaction between depression severity and a history of suicide attempts. Based on the Integrated Motivational Volitional model, when depression is markedly elevated among bereaved adolescents, individuals are more likely to experience intensified hopelessness and feelings of entrapment during the motivational phase. Entrapment is a core psychological state predicting suicidal ideation within this model8. A history of suicide attempts represents a key vulnerability factor in the volitional phase, potentially rendering suicide-related “scripts” more readily activated and lowering the threshold for the transition from distress to suicide-related thoughts. Therefore, when high levels of depression co-occur with a history of suicide attempts, these two pathways overlap and mutually amplify, resulting in an increased risk of suicidal ideation that exceeds the simple additive effects of each factor alone. In future suicide prevention efforts for bereaved adolescents within psychological support hotlines, stratified identification and intervention based on combinations of risk factors should be implemented. In particular, bereaved adolescents with both high levels of depression and a history of suicide attempts should be prioritized for assessment, crisis intervention, and ongoing follow-up to more effectively reduce suicidal ideation.

Although this study provides important findings on suicide ideation among bereaved adolescents, it still has certain limitations. First, the sample in this study was drawn from a psychological helpline population, which may differ from the general adolescent population in terms of mental health status and help-seeking behaviors, thereby limiting the external validity of the findings. Second, the hotline assessment tool used in this study did not include items related to psychotic symptoms, making it impossible to identify potential psychotic disorders or control for their potential impact in the analysis. Additionally, this study did not include a non-bereaved control group or a general population comparison group, so the results only reflect associations within the help-seeking sample. They cannot be used to estimate the overall prevalence of suicidal ideation or to confirm that these factors are specific risk factors for bereavement. Additionally, the sample size of the non-suicidal ideation group was substantially smaller than that of the suicidal ideation group, which may affect the robustness and statistical power of between-group comparisons. Therefore, future research should expand sample sources to include community, school, and clinical populations. Additionally, it should collect more comprehensive bereavement-related variables and adopt a longitudinal design with multi-timepoint follow-up to examine the trajectories of suicidal ideation in bereaved adolescents and their potential influencing factors. Future studies should also include appropriate control groups within more representative samples to further validate the findings of this study, provide more precise and systematic evidence, and offer stronger theoretical support for psychological interventions and suicide prevention among bereaved adolescents.

Conclusion

This study explored risk factors associated with suicidal ideation within a sample of bereaved adolescents seeking help through a psychological support hotline. The results indicated that, within the adolescent hotline sample, severe hopelessness, severe psychological distress, depression severity, grief severity, and a history of suicide attempts were risk factors for suicidal ideation among bereaved adolescents. An additive interaction was observed between depression and a history of suicide attempts. In future hotline interventions for bereaved adolescents at risk of suicide, attention should be focused on potential risk factors they may experience after bereavement, including hopelessness, psychological distress, depression severity, and grief responses, to gain a more comprehensive understanding of the mechanisms underlying suicidal ideation. Furthermore, adolescents with a history of suicide attempts in the hotline should receive heightened attention to effectively prevent the occurrence of suicidal behaviors.