CanJPsychiatry 2015;60(10):427–431

Original Research

Bullying Victimization (Being Bullied) Among Adolescents

Referred for Urgent Psychiatric Consultation:
Prevalence and Association With Suicidality

Nazanin Alavi, MD1; Nasreen Roberts, MBBS, MRCPsych (UK), FRCPC, MSc (Epid)2;
Chloe Sutton, BSc3; Nicholas Axas, MSW, RSW4; Leanne Repetti, RN5
1
Psychiatry Resident, Department of Psychiatry, Queen’s University, Kingston, Ontario.
Correspondence: Hotel Dieu Hospital, 166 Brock Street, Kingston, ON K7L 5G2; nazanin.alavi@queensu.ca.
2
Head and Chair, Department of Child and Adolescent Psychiatry, Queen’s University, Kingston, Ontario.
3
Research Assistant, Department of Child and Adolescent Psychiatry, Queen’s University, Kingston, Ontario.
4
Social Worker, Urgent Consult Clinic, Hotel Dieu Hospital, Kingston, Ontario.
5
Registered Nurse, Urgent Consult Clinic, Hotel Dieu Hospital, Kingston, Ontario.

Objective: To examine the prevalence of bullying victimization among adolescents referred

Key Words: bullying
victimization, suicidal ideation,
adolescence, urgent and
emergency psychiatric
consultation
Received August 2014, revised,
and accepted April 2015.
for urgent psychiatric consultation, to study the association between bullying victimization
and suicidality, and to examine the relation between different types of bullying and
suicidality.
Method: A retrospective chart review was conducted for all adolescents referred to a
hospital-based urgent consultation clinic. Our study sample consisted of adolescents with a
history of bullying victimization. The Research Ethics Board of Queen’s University provided
approval. Data analysis was conducted using SPSS (IBM SPSS Inc, Armonk, NY). Chi-
square tests were used for sex, suicidal ideation, history of physical and sexual abuse, and
time and type of bullying, and an independent sample t test was used for age.
Results: The prevalence of bullying victimization was 48.5% (182 of 375). There was a
significant association between being bullied and suicidal ideation (P = 0.01), and between
sex and suicidal ideation (P ≤ 0.001). Victims of cyberbullying reported more suicidal
ideation than those who experienced physical or verbal bullying (P = 0.04).
Conclusions: Bullying victimization, especially cyberbullying, is associated with increased
risk of suicidal ideation among adolescents referred for psychiatric risk assessment. The
detailed history of the type and duration of bullying experienced by the victims should be
considered when conducting a psychiatric risk assessment.

WWW

Victimisation par intimidation (se faire intimider) chez des

adolescents adressés à une consultation psychiatrique d’urgence :
prévalence et association à la suicidabilité
Objectif : Examiner la prévalence de la victimisation par intimidation chez des adolescents
adressés à une consultation psychiatrique d’urgence, étudier l’association entre la
victimisation par intimidation et la suicidabilité, et examiner la relation entre différents types
d’intimidation et la suicidabilité.
Méthode : Un examen rétrospectif des dossiers a été mené pour tous les adolescents
adressés à une clinique de consultation d’urgence en milieu hospitalier. L’échantillon
de notre étude se composait d’adolescents ayant des antécédents de victimisation par
intimidation. Le comité d’éthique de la recherche de l’Université Queen’s a donné son
approbation. L’analyse des données a été menée à l’aide de SPSS (IBM SPSS Inc,
Armonk, NY). Des tests chi-carrés ont été utilisés pour le sexe, l’idéation suicidaire, les
antécédents d’abus physique et sexuel, ainsi que le moment et le type de l’intimidation.
Un test t d’échantillon indépendant a servi pour l’âge.

www.TheCJP.ca The Canadian Journal of Psychiatry, Vol 60, No 10, October 2015 W 427
Original Research

Résultats : La prévalence de la victimisation par intimidation était de 48,5 %

(182 sur 375). Il y avait une association significative entre se faire intimider et l’idéation
suicidaire (P = 0,01), et entre le sexe et l’idéation suicidaire (P ≤ 0,001). Les victimes
de cyberintimidation déclaraient plus d’idéation suicidaire que celles qui subissaient
l’intimidation physique ou verbale (P = 0,04).
Conclusions : La victimisation par intimidation, en particulier par cyberintimidation,
est associée à un risque accru d’idéation suicidaire chez les adolescents adressés
à une évaluation de risque psychiatrique. Le récit détaillé du type et de la durée de
l’intimidation subie par les victimes devrait être pris en compte lors d’une évaluation
de risque psychiatrique.

B ullying and victimization is a universal public

health concern that affects a significant proportion
of adolescents.1 Bullying is characterized by repeated
aggressive behaviour with the intention to harm the
victim, and an imbalance in power between the bullies
and their victims, making it difficult for the victims to
defend themselves.2–4 Bullying may be direct or indirect
aggression, it may be verbal, physical, psychosocial,
emotional, or cyber bullying.5–7 In the last decade,
research has shown that about 10% to 30% of children and
adolescents are recurrently involved in school bullying,
either as victims, bullies, or bully-victims.8,9 Factors
that confer risk for bullying victimization include being
female, low socioeconomic status, belonging to a minority
group, being overweight, having a learning disability, and
having poor social skills.10 There is growing evidence
that bullying victimization may have numerous negative,
long-term mental health consequences, including anger,
sadness, anxiety, depression, self-harm, and suicidal
ideation and attempts.7,8 Further, both bullies and victims
are overrepresented among those seen by mental health
professionals. One study found that about 24% of victims,
42% of bullies, and 44% of bully-victims had contact with
mental health professionals, compared with 13% of control
subjects.11
There have been very few studies on the association
between  bullying victimization and psychiatric disorders
in clinical populations. A Finnish study12 investigated the
association between bullying, suicide attempts, and self-
mutilation among 508 adolescents, aged 12 to 17 years,
who were admitted to inpatient psychiatric units. The results
showed that 61 boys and 115 girls were victims of bullying.
Self-harm was present in 21 boys and 74 girls, and 78 girls
and 26 boys had made a suicide attempt. After adjusting for
age, family factors, and psychiatric disorders, there was a
higher risk of suicide attempts in girls who were bullied or
who bullied others.12 The authors recommended psychiatric
evaluation of bullying behaviour, as this may be an early
marker of psychiatric disorders.12 A Norwegian cross-
sectional study13 of 685 patients aged 13 to 18 years used
an electronic questionnaire that showed that 19% reported
being bullied often or very often, and 51% reported being
Clinical Implications
• History of bullying victimization would be helpful when
assessing adolescents for risk of suicide.
• Specific questions about cyberbullying are merited
when conducting an assessment for risk of suicide.
Limitations
• Standard questionnaires for bullying were not used.
• There is no information on whether both bullying and
being a bullying victim coexisted.
bullied from time to time. There was an association between
being a victim of bullying and having a mood disorder.
Our study examined the prevalence of bullying victimization
(being bullied) and its association with suicidality in
adolescents referred to a hospital-based outpatient
psychiatric urgent consultation clinic.
Method
The sample for our study was drawn from the 12-month
database of an outpatient urgent consultation clinic. This
clinic provides expedited assessment of adolescents
referred by emergency department (ED) physicians, school
boards (counsellors), pediatricians, family physicians,
and community mental health agencies—if they deem the
patient urgent rather than emergent (able to wait 24 to 48
hours for assessment). Informed consent had been given by
the parents and youth to have their information included
in research studies that did not identify them individually.
From this database, we extracted youth who had been
bullied and entered their details in a separate file. Each
chart was then reviewed by the research assistant to extract
data for the variables under study, which included sex,
age, time period of being bullied (past or present), type of
bullying (verbal, physical, and [or] emotional) and history
of sexual, physical, or emotional abuse. Confidentiality was
maintained by password-protected files.
Data were entered in Microsoft Excel 2010 format,
and SPSS (IBM SPSS Inc, Armonk, NY) was used for
analyzing the data. Chi-square tests were used for sex,
suicidal ideation, history of physical and sexual abuse, time

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 Bullying Victimization (Being Bullied) Among Adolescents Referred for Urgent Psychiatric Consultation: Prevalence and Association With Suicidality
and type of bullying, and an independent sample t test was
used for age.
This study was approved by the Research and Ethics Board
of Queen’s University.
Results
During the 12-month study period, 375 patients were
assessed in the clinic, and 182 (108 females and 74 males)
of those reported a current and (or) past history of being
bullied, yielding a prevalence of 48.5%. Their average
age was 14.4 years. Table 1 shows the sociodemographic
distribution of study variables.
There was a statistically significant association between sex
and being bullied (χ2 = 135.01, df = 2, P < 0.001) (Table
2). The odds of females being bullied was 1.8 times higher
than males (OR 1.8, 95% CI 1.6 to 2.9). We did not find
an association between age and being bullied (t = 2.86,
df = 200, P = 0.09). Suicidal ideation, threats, or plan was
reported by 123 of the 182 patients and 26 reported self-
harming behaviours. There was a statistically significant
association between history of being bullied and suicidal
ideation (χ2 = 5.81, df = 1, P = 0.01). The odds of being
bullied in patients who were suicidal were 2 times higher
than those who were not (OR 2, 95% CI 1.5 to 3.2) (Table
3 shows the distribution by type of bullying). Patients
who were cyberbullied reported more suicidal ideation,
compared with those who were verbally bullied (χ2 = 4.09,
df = 1, P = 0.04) (Table 3). Suicidal ideation was 3.6 times
higher in those who experienced cyberbullying (OR 3.6,
95% CI 1.3 to 10.9). However, there was no statistically
significant difference between being both physically and
verbally bullied and being cyberbullied (χ2 = 2.34, df = 2,
P = 0.12) (Table 2). There was no significant difference in
suicidality between those with a past or present history of
being bullied (χ2 = 0.2, df = 1, P = 0.3) and no association
between being bullied and history of abuse (Table 2).
Discussion
Our study aimed to examine the prevalence of bullying
victimization and its relation with suicidal ideation among
adolescents seen in an outpatient psychiatric clinic for risk
assessment. Unlike other studies involving adolescents
and bullying victimization, ours was a prospective study
that measured victimization in a population of adolescent
patients referred for urgent psychiatric assessment. Our
prevalence rate (48.53%) was much higher than in the
general population, and higher than that reported for other
mental health clinics and inpatient populations.14 This
finding is explicable based on the demographics of our
population and the referral patterns in our region.18 There
are a disproportionate number of prisons in our region; we
have a large proportion of single-parent families on social
www.TheCJP.ca
Table 1 Sociodemographic factors and distribution
of study variables of patients who were bullied (total
n = 182)
Factors n %
Sex
Male 74 40.7
Female 108 59.3
History of abuse
Physical 8 4.4
Sexual 14 7.7
Emotional 10 5.5
Physical and emotional 11 6.0
Physical and sexual 3 1.6
Sexual and emotional 1 0.5
All 4 2.2
None 130 71.4
assistance and children with multiple biopsychosocial
vulnerabilities. The local school boards, community
mental health agencies, pediatricians, and ED physicians
have had training for appropriate use of the urgent clinic
in triaging high-risk patients. In examining the relation
between suicidality and being bullied, our results replicate
those from previous studies; there is a higher prevalence of
suicidal ideation and self-harm behaviours among bullied
patients.2,5,15 In our study, females were overrepresented,
similar to previous studies16,17; this is explicable based on
existing information that females are more likely to express
their distress, either directly or indirectly, to friends and
family and are more willing to seek mental health help.
Males are less likely to do so and may only present to the ED
having made a suicide attempt, leading to admission to the
hospital, rather than to an urgent consultation referral.16,18–20
The type of bullying experienced by participants was also
consistent with reports from victims of bullying in other
studies.1,15 Verbal aggression was the most common among
victims, and physical aggression (for example, hitting,
pushing, and kicking) was a less common occurrence. This
result may be partly explicable based on the zero tolerance
policy for physical aggression in schools. Congruent with
prior research,7 involvement in cyberbullying was found
to be less frequent than other forms of bullying. However,
significant links were found between being cyberbullied and
suicidal ideation. Further, students who are cyberbullied
are less likely to report and seek help than those who are
bullied by more traditional means, decreasing their levels of
social support and putting them at a greater risk of suicidal
ideation.7
ED staff would be well advised to ask whether the youth
is being threatened or demeaned on social media, such as
Facebook, emails, and (or) texting. Unlike traditional forms
The Canadian Journal of Psychiatry, Vol 60, No 10, October 2015 W 429
Original Research

Table 2 Results of chi-square tests for sex, suicidal ideation (SI),

type, and time of bullying
Risk factor χ2a P OR
Female sex and bullying 135 <0.001 1.8
Bullying and SI 5.8 0.01 2.0
Cyberbullying and SI 4.1 0.04 3.6
Physical and verbal 2.3 0.12 n/a
bullying and SI
Current bullying and SI 0.2 0.3 n/a
a
df = 1
n/a = not applicable

Table 3 Bullying and suicidality among psychiatric urgent

consultation patients (total n = 182)
Factor n %
Suicidal ideation 123 67.6
Self-harming behaviour 26 14.3
Types of bullying
Verbal 55 30.2
Physical 2 1.1
Cyber 9 4.9
Verbal and physical 27 14.8
Verbal and cyber 12 6.6
All 11 6.0
Nonspecified 66 36.3
Time of bullying
Current 76 41.8
Past 41 22.5
Both 65 35.7

of bullying, cyberbullying has characteristics that make it
much more pernicious than traditional bullying, such as
the victim may continue to receive emails, Facebook or
Twitter messages, or text messages regardless of time and
place; and the possibility of widespread dissemination of
demeaning or threatening material to a large audience of
peers. Further, cyberbullies feel protected and have a sense
of invisibility and anonymity. This feeling of invisibility can
also allow bullies to be less aware of the consequences of
their actions, and without such direct feedback, the bullies
may have less empathy or remorse, and also less opportunity
for bystander (teacher, parent, or peer) intervention.20 The
introduction of social networks (MySpace, Facebook,
Twitter, and Instagram) has provided new forums for
relational conflict.17 Awareness of the risks inherent in the
increased access to the Internet and other technologies, and
the possible increased risk of cyberbullying, is important
for health care professionals.
led to suicides among females. Thus a detailed history of
the extent and type of bullying should form an integral part
of a suicide risk assessment in youth.
Strengths and Limitations
The strength of our study lies in its prospective design, and it
is one of a very few studies on outpatient clinic populations.
A limitation is that we did not use any specific bullying
questionnaire, and data were derived from history only. We
have no information on whether the victims were bullies
themselves, as there is evidence to suggest that bullying and
being bullied can be present in the same person.
Future Directions
A larger outpatient prospective study on bullying
victimization with structured questionnaires for both youth
and parents, and special attention to the growing problem of
cyberbullying would add to existing knowledge.

Conclusion Acknowledgements
Bullying victimization is a potential risk factor for suicidal This study was partially funded through a Southeastern
behaviour among youth. In recent years, cyberbullying has Ontario Medical Organization innovations grant ($55 000)

430 W La Revue canadienne de psychiatrie, vol 60, no 10, octobre 2015 www.LaRCP.ca
 Bullying Victimization (Being Bullied) Among Adolescents Referred for Urgent Psychiatric Consultation: Prevalence and Association With Suicidality
for the study of the school-based mental health curriculum
and its impact on ED referrals. Dr Alavi won the American
Psychiatric Association (APA)–Lily Resident Research
Award at the 2014 APA conference for this research. The
authors declare no conflicts of interest.
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