Depressive symptoms co-occurring with forced sexual intercourse, bullying, or substance use are associated with super-additive suicide-attempt prevalence among U.S. adolescents

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Depression screening is central to adolescent suicide prevention, yet depression alone may not identify adolescents with particularly high suicide-attempt prevalence when violence, bullying, or substance use is also reported. We conducted a pooled cross-sectional analysis of nationally representative 2019, 2021, and 2023 U.S. Youth Risk Behavior Survey data ( n = 51,012) using survey-weighted regression with 50 multiply imputed datasets. Additive interaction was estimated using population-average adjusted risks. Interaction contrasts (ICs, percentage points) were positive for forced sexual intercourse (16.596, 95% CI 12.004–21.188), cyberbullying (11.898, 9.424–14.371), substance use (11.194, 8.942–13.445), and school bullying (10.168, 7.643–12.693). Adjusted risks in the joint-indicator groups ranged from 27.531% for substance use to 42.283% for forced sexual intercourse. Mutually adjusted ICs remained positive (range 2.831–9.351% points). Multiplicative interaction was supported for substance use and forced sexual intercourse in separate models, but only for substance use in the mutually adjusted model. These co-occurring indicators warrant prospective evaluation. Temporal ordering and causal mechanisms remain unresolved.

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