Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016

Self-harm as a predisposition for suicide attempts: A study of adolescents' deliberate self-harm, suicidal ideation, and suicide attempts

The aim of this study was to analyze the predictive risk factors for self-harm in adolescents with and without suicidal ideation. 600 adolescents answered a questionnaire about self-harm and suicidal behaviors. A logistic regression analysis was conducted. Over half of the individuals with deliberate self-harm (DSH) presented significant suicide risk. There was a direct association between DSH and suicide attempts, with almost the totality of the adolescents with suicide attempts also reporting DSH. According to the prediction model, suicidal ideation and diversity of DSH behaviors are significant predictors of suicide attempts, with an augmentation in the diversity of DSH behaviors and suicidal ideation predicting suicide attempts. Depression and anxiety appeared also as significant predictors of suicide attempts in adolescent self-harmers. Considering that the majority of the sample was not from a clinical setting, an alarming finding was that one third of the total sample was at suicide risk. These results place DSH as a key variable for early intervention.

A comparison between American and Chinese college students on suicide-related behavior parameters

BACKGROUND/OBJECTIVE

The United States (US) and China are the two largest economies, but recent and directly comparable studies on suicide-related behaviors in the two countries are lacking. By using the Suicidal Behaviors Questionnaire-Revised (SBQ-R), item-level comparison was performed in assessing self-reported suicide-related behaviors between the US and Chinese undergraduates.

METHOD

This study involved a total of 3,185 college students aged between 18 to 24 years (1,185 US college students, and 2,000 Chinese students who were randomly selected from a large sample of 11,806 Chinese college students). Participants filled out the 4-item SBQ-R.

RESULTS

Participants' responses were compared by country and sex. There was a higher overall risk of suicide-related behaviors among US students (24.3%) compared to Chinese students (17.0%). US students also reported higher lifetime attempt, past-year ideation, and lifetime threat. US female college students reported the highest suicide-related behaviors compared to other sub-groups.

CONCLUSIONS

There is a need to tailor specific interventions to alleviate college students' suicide-related behaviors in the US and China, with a particular focus on US females.

An Enhanced Social Networking Intervention for Young People with Active Suicidal Ideation: Safety, Feasibility and Acceptability Outcomes

Online social networking interventions have potential to support young people who experience suicidal thoughts by specifically addressing interpersonal risk factors for suicide, but may also pose a risk of harm. This uncontrolled, single-group pilot study aimed to evaluate the safety, feasibility, and acceptability of an enhanced online social networking intervention ("Affinity") among a sample of young people who experienced active suicidal ideation, and to explore potential changes in clinical outcomes and the therapeutic targets of the intervention. Twenty young people with current or recent suicidal ideation who were receiving treatment for depression at a tertiary-level mental health service were given access to Affinity for two months. Participants were assessed at baseline and 8-week follow-up; 90 percent reported clinical suicidal ideation at baseline. A priori criteria related to feasibility, safety and acceptability were satisfied. In terms of potential clinical effects, significant and reliable pre-post improvements were found on self-report outcomes including suicidal ideation. This study provides initial world-first evidence to support the use of an online intervention incorporating social networking as an adjunct to treatment for young people who experience suicidal ideation. The effectiveness of Affinity needs to be evaluated in a randomised controlled trial.

Risk and protective factors for childhood suicidality: a US population-based study

BACKGROUND

Childhood suicidal ideation and behaviours are poorly understood. We examined correlates of suicidality in a US population-based sample of children participating in the Adolescent Brain and Cognitive Development (ABCD) study. The ABCD study aims to examine trajectories of mental health from childhood to adulthood and collects information on multiple domains, including mental and physical wellbeing, brain imaging, behavioural and cognitive characteristics, and social and family environment. We sought to identify and rank risk and protective factors for childhood suicidal thoughts and behaviours across these multiple domains and evaluate their association with self-agreement and caregiver agreement in reporting suicidality.

METHODS

The ABCD sample comprises a cohort of 11 875 children aged 9-10 years. The sociodemographic factors on which the sample was recruited were age, sex, race, socioeconomic status, and urbanicity. Participants were enrolled at 22 sites, the catchment area of which encompassed over 20% of the entire US population in this age group. Multistage sampling was used to ensure both local randomisation and representativeness of sociodemographic variation of the ABCD sample. The data used in this study were accessed from the ABCD Study Curated Annual Release 2.0. Suicidal thoughts and behaviours (suicidality) in each child were evaluated through independent child and caregiver reports based on the computerized Kiddie Schedule for Affective Disorders and Schizophrenia for DSM-5 (KSADS-5). We used bootstrapped logistic regression to quantify the association between suicidal ideation and behaviours, with measures of mental and physical wellbeing, behaviour, cognition, and social and family environment in participants from the ABCD study.

FINDINGS

Our study sample comprised 7994 unrelated children (mean age 9·9 years [SD 0·5]; 4234 [53%] male participants) with complete data on child-reported and caregiver-reported suicidal ideas and behaviours. Overall, 673 (8·4%) children reported any past or current suicidal ideation, 75 (0·9%) had any past or current suicidal plans, and 107 (1·3%) had any past or current suicidal attempts. According to caregivers, 650 (8·1%) of the children reported any past or current suicidal ideation, 46 (0·6%) reported any past or current suicidal plans, and 39 (0·5%) reported past or current suicidal attempts. However, inter-informant agreement was low (Cohen's κ range 0·0-0·2). Regardless of informant, child psychopathology (odds ratio [OR] 1·7-4·8, 95% CI 1·5-7·4) and child-reported family conflict (OR 1·4-1·8, 95% CI 1·1-2·5) were the most robust risk factors for suicidality. The risk of child-reported suicidality increased with higher weekend screen use time (OR 1·3, 95% CI 1·2-1·7) and reduced with greater parental supervision and positive school involvement (for both OR 0·8, 95% CI 0·7-0·9). Additionally, caregiver-reported suicidality was positively associated with caregiver educational level (OR 1·3, 95% CI 1·1-1·5) and male sex in children (1·5, 1·1-2·0), and inversely associated with the number of household cohabitants (0·8, 0·7-1·0).

INTERPRETATION

We identified risk and protective factors that show robust and generalisable associations with childhood suicidality. These factors provide actionable targets for optimising prevention and intervention strategies, support the need to identify and treat psychopathology in school-age children, and underscore the importance of school and family interventions for childhood suicidality.

FUNDING

National Institutes of Health.

A scientometric analysis of suicide research: 1990-2018

BACKGROUND

Increasing knowledge on suicide prevention has been shown to be important for suicide prevention. This paper exams the accomplishment of research on suicide and examine how those research activities contribute to the change of suicide rates.

METHODS

Data of the publications relating to suicide from 1990 to 2018 were retrieved from the Web of Science and Scopus. Bibliographic information was analyzed and the relationships between suicide rates with the number of publications per million population and the average article citations per year were examined.

RESULTS

From 1990 to 2018, globally, publications on suicide have increased significantly. The United States ("USA") had the greatest number of publications. Research collaborations among different countries/regions have been flourishing and multinational centers have become more common than ever. Nonetheless, in some countries/regions with high rates of suicide, suicide research was scarce. It was found that the number of publications per million population and the average article citations per year were negatively correlated with the suicide rates at the global level (r = - 0.96, p < 0.001; r = -0.91, p < 0.001, respectively), but not in the higher SDI regions (r = -0.05, p = 0.81; r = 0.02, p = 0.91, respectively). Furthermore, research focusing on suicide intervention was also relatively limited.

LIMITATION

The origins of the publications were only based on the corresponding authors' regions.

CONCLUSIONS

There is significant imbalance in the amount of research effort especially in the regions with high suicide rates. In the higher socioeconomic level regions, the quantity and quality of publications sometimes do not transpire in the reduction of suicide rates. A better connection between the fundamental and practical suicide research should be established. More resources should be made available to the low- and middle-income countries/regions with higher suicide risks, then the effect of suicide prevention might be much more significant.

Suicide in Rural Australia: Are Farming-Related Suicides Different?

Rural Australians experience a range of health inequities—including higher rates of suicide—when compared to the general population. This retrospective cohort study compares demographic characteristics and suicide death circumstances of farming- and non-farming-related suicides in rural Victoria with the aim of: (a) exploring the contributing factors to farming-related suicide in Australia’s largest agricultural producing state; and (b) examining whether farming-related suicides differ from suicide in rural communities. Farming-related suicide deaths were more likely to: (a) be employed at the time of death (52.6% vs. 37.7%, OR = 1.84, 95% CIs 1.28–2.64); and, (b) have died through use of a firearm (30.1% vs. 8.7%, OR = 4.51, 95% CIs 2.97–6.92). However, farming-related suicides were less likely to (a) have a diagnosed mental illness (36.1% vs. 46.1%, OR=0.66, 95% CIs 0.46–0.96) and, (b) have received mental health support more than six weeks prior to death (39.8% vs. 50.0%, OR = 0.66, 95% CIs 0.46–0.95). A range of suicide prevention strategies need adopting across all segments of the rural population irrespective of farming status. However, data from farming-related suicides highlight the need for targeted firearm-related suicide prevention measures and appropriate, tailored and accessible support services to support health, well-being and safety for members of farming communities.

Trends in Suicide Mortality in South Africa, 1997 to 2016

Suicide rates worldwide are declining; however, less is known about the patterns and trends in mortality from suicide in sub-Saharan Africa. This study evaluates trends in suicide rates and years of potential life lost from death registration data in South Africa from 1997 to 2016. Suicide (X60–X84 and Y87) was coded using the 10th Revision of the International Classification of Diseases (ICD-10). Changes in mortality rate trends were analysed using joinpoint regression analysis. The 20-year study examines 8573 suicides in South Africa, comprising 0.1% of all deaths involving persons 15 years and older. Rates of suicide per 100,000 population were 2.07 in men and 0.49 in women. Joinpoint regression analyses showed that, while the overall mortality rate for male suicides remained stable, mortality rates due to hanging and poisoning increased by 3.9% and 3.5% per year, respectively. Female suicide mortality rates increased by 12.6% from 1997 to 2004 before stabilising; while rates due to hanging increased by 3.0% per year. The average annual YPLL due to suicide was 9559 in men and 2612 in women. The results show that suicide contributes substantially to premature death and demonstrates the need for targeted interventions, especially among young men in South Africa.

Association of suicidal behavior with exposure to suicide and suicide attempt: A systematic review and multilevel meta-analysis

BACKGROUND

Exposure to suicidal behavior may be associated with increased risk of suicide, suicide attempt, and suicidal ideation and is a significant public health problem. However, evidence to date has not reliably distinguished between exposure to suicide versus suicide attempt, nor whether the risk differs across suicide-related outcomes, which have markedly different public health implications. Our aim therefore was to quantitatively assess the independent risk associated with exposure to suicide and suicide attempt on suicide, suicide attempt, and suicidal ideation outcomes and to identify moderators of this risk using multilevel meta-analysis.

METHODS AND FINDINGS

We systematically searched MEDLINE, Embase, PsycINFO, CINAHL, ASSIA, Sociological Abstracts, IBSS, and Social Services Abstracts from inception to 19 November 2019. Eligible studies included comparative data on prior exposure to suicide, suicide attempt, or suicidal behavior (composite measure-suicide or suicide attempt) and the outcomes of suicide, suicide attempt, and suicidal ideation in relatives, friends, and acquaintances. Dichotomous events or odds ratios (ORs) of suicide, suicide attempt, and suicidal ideation were analyzed using multilevel meta-analyses to accommodate the non-independence of effect sizes. We assessed study quality using the National Heart, Lung, and Blood Institute quality assessment tool for observational studies. Thirty-four independent studies that presented 71 effect sizes (exposure to suicide: k = 42, from 22 independent studies; exposure to suicide attempt: k = 19, from 13 independent studies; exposure to suicidal behavior (composite): k = 10, from 5 independent studies) encompassing 13,923,029 individuals were eligible. Exposure to suicide was associated with increased odds of suicide (11 studies, N = 13,464,582; OR = 3.23, 95% CI = 2.32 to 4.51, P < 0.001) and suicide attempt (10 studies, N = 121,836; OR = 2.91, 95% CI = 2.01 to 4.23, P < 0.001). However, no evidence of an association was observed for suicidal ideation outcomes (2 studies, N = 43,354; OR = 1.85, 95% CI = 0.97 to 3.51, P = 0.06). Exposure to suicide attempt was associated with increased odds of suicide attempt (10 studies, N = 341,793; OR = 3.53, 95% CI = 2.63 to 4.73, P < 0.001), but not suicide death (3 studies, N = 723; OR = 1.64, 95% CI = 0.90 to 2.98, P = 0.11). By contrast, exposure to suicidal behavior (composite) was associated with increased odds of suicide (4 studies, N = 1,479; OR = 3.83, 95% CI = 2.38 to 6.17, P < 0.001) but not suicide attempt (1 study, N = 666; OR = 1.10, 95% CI = 0.69 to 1.76, P = 0.90), a finding that was inconsistent with the separate analyses of exposure to suicide and suicide attempt. Key limitations of this study include fair study quality and the possibility of unmeasured confounders influencing the findings. The review has been prospectively registered with PROSPERO (CRD42018104629).

CONCLUSIONS

The findings of this systematic review and meta-analysis indicate that prior exposure to suicide and prior exposure to suicide attempt in the general population are associated with increased odds of subsequent suicidal behavior, but these exposures do not incur uniform risk across the full range of suicide-related outcomes. Therefore, future studies should refrain from combining these exposures into single composite measures of exposure to suicidal behavior. Finally, future studies should consider designing interventions that target suicide-related outcomes in those exposed to suicide and that include efforts to mitigate the adverse effects of exposure to suicide attempt on subsequent suicide attempt outcomes.

Late life suicide in Italy, 1980-2015

AIM

Suicide trends in older adults were examined in Italy from 1980 to 2015. Age groups considered were 65-74 years, 75-84 and 85 + years.

METHODS

Data on suicide deaths were obtained from the Italian Mortality Database (IMDB) collected by the Italian National Institute of Statistics (ISTAT) and processed by the Statistics Unit of the Italian National Institute of Health (Istituto Superiore di Sanità). Joinpoint regression analyses were carried out for age subgroups by sex. In addition, data related to four main macro-areas of Italy were considered: North-West, North-East, Centre, and South with Islands (Sicily and Sardinia).

RESULTS

Starting by 1985, declines were noted in all age groups with more noticeable decreases in older adults aged 75-84 and 85 + years. Female subjects demonstrated more ample falls in rates than male individuals. Declines were detected in all macro-areas of Italy.

CONCLUSION

Improved health assistance and quality of life of older individuals have probably contributed to the decline of suicide rates of senior citizens, who also showed improved poverty indices in the country, differently from all other age groups.

Annual Research Review: Adolescent mental health in the digital age: facts, fears, and future directions

Adolescents are spending an increasing amount of their time online and connected to each other via digital technologies. Mobile device ownership and social media usage have reached unprecedented levels, and concerns have been raised that this constant connectivity is harming adolescents' mental health. This review synthesized data from three sources: (a) narrative reviews and meta-analyses conducted between 2014 and 2019, (b) large-scale preregistered cohort studies and (c) intensive longitudinal and ecological momentary assessment studies, to summarize what is known about linkages between digital technology usage and adolescent mental health, with a specific focus on depression and anxiety. The review highlights that most research to date has been correlational, focused on adults versus adolescents, and has generated a mix of often conflicting small positive, negative and null associations. The most recent and rigorous large-scale preregistered studies report small associations between the amount of daily digital technology usage and adolescents' well-being that do not offer a way of distinguishing cause from effect and, as estimated, are unlikely to be of clinical or practical significance. Implications for improving future research and for supporting adolescents' mental health in the digital age are discussed.

[The influence of religiosity on depressive disorders and suicidal behavior]

This review of the literature is focused on the positive influence of religiosity on recovery after depression and on the protective role of religiosity against suicidal activity. Despite the inconsistent results on the role of religiosity in treatment of mental diseases, to date there is a sufficiently large body of literature showing the beneficial effect of religiosity and describing specific therapeutic approaches and suicide prevention programs.

Spatial clustering of suicide mortality and associated community characteristics in Kanagawa prefecture, Japan, 2011-2017

BACKGROUND

Suicide mortality is high in Japan and early interventional strategies to solve that problem are needed. An accurate evaluation of the regional status of current suicide mortality would be useful for community interventions. A few studies in Kanagawa prefecture, located next to Tokyo and with the second largest population in Japan, have identified spatial clusters of suicide mortality at regional levels. This study examined spatial clustering and clustering over time of such events using spatial data from regional statistics on suicide deaths.

METHODS

Data were obtained from regional statistics (58 regions in Kanagawa prefecture) of the National Vital Statistics of Japan from 2011 to 2017. The standardized mortality ratio (SMR) and Empirical Bayes estimator for the SMR (EBSMR) were used as measures. Spatial clusters were examined by Kulldorff's circular spatial scan statistic, Tango-Takahashi's flexible spatial scan statistic and Tango's test. Linear regression and conditional autoregressive (CAR) models were used not only to adjust for covariates but also to estimate regional effects. The analyses were conducted for each year, inclusive.

RESULTS

Among male suicide deaths, being unemployed (50%) was most frequently related to suicide while among female health problem (50%) were frequent. Spatial clusters with significance detected by FlexScan, SatScan and Tango's test were few and varied somewhat according to the method used. Spatial clusters were detected in some regions including Kawasaki ward after adjustment by covariates. By the linear regression models, selected variables with significance were different between the sexes. For males, unemployment, family size, and proportion of higher education were detected for several of the years studied while for females, family size and divorce rate were detected over this period. These variables were also observed by the CAR model with 5 covariates. Regional effects were much clearer by considering the spatial parameter for both males and females and especially, Kawasaki ward was detected as a high risk region in many years.

CONCLUSION

The present results detected some spatial clustering of suicide deaths within certain regions. Factors related to suicide deaths were also indicated. These results would provide important information in policy making for suicide prevention.

Self-reported disability and quality of life in an online Australian community sample with suicidal thoughts

BACKGROUND

Limited research has been conducted to quantify the level of disability and health related quality of life (HRQoL) associated with suicidal thoughts and behaviour. The aims of the current study were to (1) describe levels of disability and HRQoL in an Australian sample of adults with suicidal ideation, (2) examine the effect of zero, one, or more than one previous suicide attempt on disability and HRQoL, and (3) describe the demographic and clinical characteristics associated with disability and HRQoL.

METHOD

Data for the current study is drawn from the baseline assessment of the Healthy Thinking trial that evaluated the effectiveness of an online self-help program for suicidal thoughts in an Australian adult community sample (n = 418). Measures of disability, quality of life, clinical symptoms, suicidality and demographic variables were included.

RESULTS

The mean disability score for the overall sample was 19.2 (SD = =8.9), while the mean perceived physical health score was 40.7 (SD = =6.5) and the mean perceived mental health score was 36.1 (SD = =5.9). Higher levels of disability and lower levels of perceived physical health were associated with multiple suicide attempts compared to one or no history of suicide attempt.

LIMITATIONS

Limitations included the limited generalisability of results, the use of self-report to assess suicide attempts, and the use of cross-sectional data.

CONCLUSION

Suicidal thoughts and behaviours are associated with high levels disability and low levels of perceived physical and mental health. Early intervention programs are needed to reduce the high levels of burden associated with suicidality.

Suicide among people treated for drug use disorders: a Danish national record-linkage study

Background

Substance use disorders are a major risk factor for suicide. However, less is known about specific risk factors for suicide in people with substance use disorders.

Methods

This population cohort study assessed suicide among people treated for drug use disorders in Denmark 2000–2010, and described risk factors for completed suicide. Data from 27,942 individuals enrolled in treatment were linked to national registers and matched with controls without drug use disorder and with (n = 138,136) or without psychiatric history (n = 1574). Competing risk regression was used to identify risk factors of completed suicide.

Results

There were 163 suicides among patients with a history of drug treatment (0.6% of patients). Increased risk was associated with younger age at enrolment (hazard ratio [HR] = 0.97, 95% confidence interval (CI): 0.95, 0.98), history of psychiatric care (HR = 1.96, CI 95%: 1.39, 2.77), opioid use (HR = 1.81, 95% CI: 1.23, 2.68), and alcohol use (HR = 1.56, 95% CI: 1.09, 2.23). Lower risk was associated with cannabis use (HR = 0.69, 95% CI: 0.50, 0.96). Compared with age- and gender-matched controls without a history of treatment for substance use disorders or recent psychiatric care, the standardized mortality ratio due to suicide was 7.13 for people with drug use disorder without a history of psychiatric care (95% CI: 5.81, 8.44), 13.48 for people with drug use disorder and psychiatric history (95% CI: 9.75, 17.22), and 13.61 for people with psychiatric history only (95% CI: 6.72, 20.50).

Conclusions

Risk of suicide is increased among people with drug use disorders. Access to treatment for co-morbid mental health problems for people with drug use disorders could potentially reduce risk of suicide.

Suicide

Throughout the world, approximately 800,000 people die by suicide every year, accounting for 1.5% of all deaths. Suicide is the 10th leading cause of death in North America and the foremost cause of death worldwide among persons 15 to 24 years of age.

Online-group intervention after suicide bereavement through the use of webinars: study protocol for a randomized controlled trial

Introduction

The death of a significant person through suicide is a very difficult experience and can have long-term impact on an individual’s psychosocial and physical functioning. However, there are only few studies that have examined the effects of interventions in suicide survivors. In the present study, we examine an online-group intervention for people bereaved by suicide using a group-webinar.

Methods

The intervention was developed based on focus groups with the target group. The cognitive-behavioral 12-module webinar-based group intervention focuses on suicide bereavement-related themes such as feelings of guilt, stigmatization, meaning reconstruction and the relationship to the deceased. Further, the webinar includes testimonial videos and psychoeducation. The suicide survivors are randomized to the intervention or the waiting list in a group-cluster randomized controlled trial. Primary outcomes are suicidality (Beck Scale for Suicide Ideation) and depression (Beck Depression Inventory-II) and secondary outcomes are symptoms of prolonged grief disorder (Inventory of Complicated Grief-German Version ), posttraumatic stress disorder ( Revised Impact of Event Scale ), stigmatization (Stigma of Suicide and Suicide Survivor ) and posttraumatic cognitions (Posttraumatic Cognitions Inventory).

Discussion

Previous studies of Internet-based interventions for the bereaved were based on writing interventions showing large treatment effects. Little is known about the use of webinars as group interventions. Advantages and challenges of this novel approach of psychological interventions will be discussed.

Trial registration

German Clinical Trials Register, DRKS00014426. Registered on 12 April 2018.

Protocol Version

3, 21.10.2019.

Prediction of Sex-Specific Suicide Risk Using Machine Learning and Single-Payer Health Care Registry Data From Denmark

Importance

Suicide is a public health problem, with multiple causes that are poorly understood. The increased focus on combining health care data with machine-learning approaches in psychiatry may help advance the understanding of suicide risk.

Objective

To examine sex-specific risk profiles for death from suicide using machine-learning methods and data from the population of Denmark.

Design, Setting, and Participants

A case-cohort study nested within 8 national Danish health and social registries was conducted from January 1, 1995, through December 31, 2015. The source population was all persons born or residing in Denmark as of January 1, 1995. Data were analyzed from November 5, 2018, through May 13, 2019.

Exposures

Exposures included 1339 variables spanning domains of suicide risk factors.

Main Outcomes and Measures

Death from suicide from the Danish cause of death registry.

Results

A total of 14 103 individuals died by suicide between 1995 and 2015 (10 152 men [72.0%]; mean [SD] age, 43.5 [18.8] years and 3951 women [28.0%]; age, 47.6 [18.8] years). The comparison subcohort was a 5% random sample (n = 265 183) of living individuals in Denmark on January 1, 1995 (130 591 men [49.2%]; age, 37.4 [21.8] years and 134 592 women [50.8%]; age, 39.9 [23.4] years). With use of classification trees and random forests, sex-specific differences were noted in risk for suicide, with physical health more important to men's suicide risk than women's suicide risk. Psychiatric disorders and possibly associated medications were important to suicide risk, with specific results that may increase clarity in the literature. Generally, diagnoses and medications measured 48 months before suicide were more important indicators of suicide risk than when measured 6 months earlier. Individuals in the top 5% of predicted suicide risk appeared to account for 32.0% of all suicide cases in men and 53.4% of all cases in women.

Conclusions and Relevance

Despite decades of research on suicide risk factors, understanding of suicide remains poor. In this study, the first to date to develop risk profiles for suicide based on data from a full population, apparent consistency with what is known about suicide risk was noted, as well as potentially important, understudied risk factors with evidence of unique suicide risk profiles among specific subpopulations.

Suicide in DSM-5: Current Evidence for the Proposed Suicide Behavior Disorder and Other Possible Improvements

Suicide continues to be one of the greatest challenges faced by mental health clinicians and researchers, an issue made worse by increasing trends in the global suicide rate. Suicide behavior disorder (SBD) was introduced in DSM-5 as a disorder for further consideration and potential acceptance into the diagnostic system. There are numerous positive developments that would arise from the addition of a suicide-related diagnosis. Utilizing the 2009 guidelines established by Kendler and colleagues, the present review examines the evidence for SBD's validity and discusses the diagnosis' potential clinical benefits and limitations. Altogether, growing evidence indicates that SBD has preliminary validity and benefit. SBD presents with several significant limitations, however, and possible alternative additions to future DSMs are highlighted.

Global goals and suicide prevention in the Circumpolar North

The purpose of this selective narrative review is to provide an overview of suicide and suicide prevention in the Circumpolar North and the relevance of global strategies and policies to these themes. We conducted a selective review of the English language literature on Arctic Indigenous mental health, suicide, and suicide prevention. We briefly present the social context, epidemiology, and risk and protective factors for suicide in the Arctic, with a focus on Indigenous peoples. We highlight a recent collaborative, intergovernmental response to elevated suicide rates in this region, the Reducing the Incidence of Suicide in Indigenous Groups - Strengths United through Networks Initiative, which used a consensus methodology to identify key outcomes for evaluating suicide prevention interventions in the circumpolar context. In relation to the Sustainable Development Goals, we examine recent policy developments in Indigenous-led suicide prevention and identify opportunities for strengthening policy, community interventions, and research. Globally, suicide prevention is a public health priority, and reducing the number of suicide deaths is a key target for sustainable development. Although overall and country-specific suicide rates have decreased since 1990, there remains wide variation at the regional and local level. This is particularly evident in the Arctic region known as the Circumpolar North, where Indigenous peoples experience marked disparities in suicide risk and suicide deaths compared to non-Indigenous populations. The factors that influence these variations are complex and often rooted in the social and economic consequences of colonization. The integration of science, community-based and Indigenous knowledge, and policies that address upstream risks for suicide will play an important role in suicide prevention alongside the growing number of Indigenous suicide prevention strategies tailored for specific populations.

Why Are Suicide Rates Increasing in the United States? Towards a Multilevel Reimagination of Suicide Prevention

Suicide, a major public health concern, takes around 800,000 lives globally every year and is the second leading cause of death among adolescents and young adults. Despite substantial prevention efforts, between 1999 and 2017, suicide and nonfatal self-injury rates have experienced unprecedented increases across the United States - as well as in many other countries in the world. This chapter reviews the existing evidence on the causes behind increased suicide rates and critically evaluates the impact of a range of innovative approaches to suicide prevention. First, we briefly describe current trends in suicide and suicidal behaviors and relate them to recent time trends in relevant suicide risk markers. Then, we review the existing evidence in suicide prevention at the individual and the population levels, including new approaches that are currently under development. Finally, we advocate for a new generation of suicide research that examines causal factors beyond the proximal and clinical and fosters a socially conscious reimagining of suicidal prevention. To this end, we emphasize the need for the conceptualization of suicide and suicidal behaviors as complex phenomena with causes at several levels of organization. Future interdisciplinary research and interventions should be developed within a multilevel causal framework that can better capture the social, economic, and political settings where suicide, as a process, unfolds across the life course.

Suicide prediction models: a critical review of recent research with recommendations for the way forward

Suicide is a leading cause of death. A substantial proportion of the people who die by suicide come into contact with the health care system in the year before their death. This observation has resulted in the development of numerous suicide prediction tools to help target patients for preventive interventions. However, low sensitivity and low positive predictive value have led critics to argue that these tools have no clinical value. We review these tools and critiques here. We conclude that existing tools are suboptimal and that improvements, if they can be made, will require developers to work with more comprehensive predictor sets, staged screening designs, and advanced statistical analysis methods. We also conclude that although existing suicide prediction tools currently have little clinical value, and in some cases might do more harm than good, an even-handed assessment of the potential value of refined tools of this sort cannot currently be made because such an assessment would depend on evidence that currently does not exist about the effectiveness of preventive interventions. We argue that the only way to resolve this uncertainty is to link future efforts to develop or evaluate suicide prediction tools with concrete questions about specific clinical decisions aimed at reducing suicides and to evaluate the clinical value of these tools in terms of net benefit rather than sensitivity or positive predictive value. We also argue for a focus on the development of individualized treatment rules to help select the right suicide-focused treatments for the right patients at the right times. Challenges will exist in doing this because of the rarity of suicide even among patients considered high-risk, but we offer practical suggestions for how these challenges can be addressed.

Risk Factors for Serious Suicide Attempts: Difference Between Older and Younger Attempters in the Emergency Department

Objective: Suicide attempts of the older adults are known to be more serious than that of the younger adults. Despite its major social impact in South Korea, the behavioral mechanism of serious suicide attempt (SSA) in old people remains to be elucidated. Thus, we investigated the risk factors for SSA in older and younger suicide attempters in the emergency department. Methods: Demographic data, clinical information, and the level of seriousness of suicide with Risk Rescue Rating Scale were compared between older (age ≥65) and younger (age <65) adults who visited the emergency department for a suicide attempt. Regression analyses were performed to identify the risk factors for SSA in these two groups. Results: Among 370 patients, 37 were older adults (10%; aged 74.41 ± 6.78), more likely to have another medical disease (p < 0.001), and a higher suicide completion rate (16.2 vs. 5.4%, p = 0.023). In the younger group, old age (B = 0.090, p < 0.001), male sex (B = -0.038, p = 0.019), and impression of schizophrenia (B = 0.074, p = 0.027) were associated with a higher risk-rescue ratio and interpersonal stress condition was associated with a lower risk-rescue ratio (B = -0.045, p = 0.006). In the older group, however, no variables were included significant in the regression model for the Risk Rescue Rating Scale. Conclusions: Demographic and clinical factors such as old age, male sex, interpersonal stress, and impression of schizophrenia were associated with lethality in the younger suicide attempters. However, no factors were associated with SSA in the older adult group. Different mechanisms may underly the lethality in old age suicide.

PEPSUI, a Psychoeducational Program for the Management of Suicidal Patients: A Qualitative Study From a Randomized Controlled Trial

BACKGROUND

Suicide prevention after a recent suicide attempt remains a major issue for clinicians. Indeed, these patients are at risk of new attempts and also less prone to interact with mental health services. As psychoeducation-based interventions are strongly recommended for patients with severe or chronic disorders and poor adherence, we developed the first French program of suicide psychoeducation (PEPSUI).

METHODS

We started a large multicenter randomized controlled trial in outpatients who attempted suicide in the last year (i.e., current suicidal behavior disorder) to assess the feasibility, acceptability, and effectiveness of a 10-week psychoeducational program (PEPSUI group: scientific information on suicidal behavior, and third-wave cognitive behavioral therapies) compared with a 10-week relaxation program (control condition), in a naturalistic setting. Here, we present the qualitative part of this study. Participants in both groups completed a narrative interview with questions on their general impressions about the therapy process and outcomes, specific areas of change in their life since inclusion, and knowledge and perceptions about suicide and mental health services. Interviews were audiotaped, transcribed, and coded using inductive and deductive thematic analysis with a constant comparative approach. Participants were consecutively included until data saturation.

RESULTS

The interviews of 18 patients (n=10 in the PEPSUI group, and n=8 in the relaxation group) were analyzed. Qualitative analyses revealed some common points, and many differences between groups that are relevant for suicide prevention. Patients in both groups were satisfied with the programs. Group modality and therapeutic alliance with the instructors were considered useful in both groups. Participation was related to improved perception of mental health units (particularly in the PEPSUI group). Both groups reported the acquisition of stress management skills and distress tolerance. Relaxation was an easy way to survive stress. Conversely, the PEPSUI program had deeper implications for daily life through effective positioning towards internal events (thoughts and emotions) as a consequence of mindfulness-derived practices, enhancement of value-based commitments, improvement of the meaning in life and internal locus of control, increased contact with the present moment, use of a matrix (a decision-making tool), and acquisition of scientific knowledge on suicidal behavior.

CONCLUSION

Through specific processes for targeting suicidal risk and reducing the stigma, the PEPSUI program may represent a promising intervention for suicide prevention.

Suicide prevention and depression apps' suicide risk assessment and management: a systematic assessment of adherence to clinical guidelines

BACKGROUND

There are an estimated 800,000 suicides per year globally, and approximately 16,000,000 suicide attempts. Mobile apps may help address the unmet needs of people at risk. We assessed adherence of suicide prevention advice in depression management and suicide prevention apps to six evidence-based clinical guideline recommendations: mood and suicidal thought tracking, safety plan development, recommendation of activities to deter suicidal thoughts, information and education, access to support networks, and access to emergency counseling.

METHODS

A systematic assessment of depression and suicide prevention apps available in Google Play and Apple's App Store was conducted. Apps were identified by searching 42matters in January 2019 for apps launched or updated since January 2017 using the terms "depression," "depressed," "depress," "mood disorders," "suicide," and "self-harm." General characteristics of apps, adherence with six suicide prevention strategies identified in evidence-based clinical guidelines using a 50-question checklist developed by the study team, and trustworthiness of the app based on HONcode principles were appraised and reported as a narrative review, using descriptive statistics.

RESULTS

The initial search yielded 2690 potentially relevant apps. Sixty-nine apps met inclusion criteria and were systematically assessed. There were 20 depression management apps (29%), 3 (4%) depression management and suicide prevention apps, and 46 (67%) suicide prevention apps. Eight (12%) depression management apps were chatbots. Only 5/69 apps (7%) incorporated all six suicide prevention strategies. Six apps (6/69, 9%), including two apps available in both app stores and downloaded more than one million times each, provided an erroneous crisis helpline number. Most apps included emergency contact information (65/69 apps, 94%) and direct access to a crisis helpline through the app (46/69 apps, 67%).

CONCLUSIONS

Non-existent or inaccurate suicide crisis helpline phone numbers were provided by mental health apps downloaded more than 2 million times. Only five out of 69 depression and suicide prevention apps offered all six evidence-based suicide prevention strategies. This demonstrates a failure of Apple and Google app stores, and the health app industry in self-governance, and quality and safety assurance. Governance levels should be stratified by the risks and benefits to users of the app, such as when suicide prevention advice is provided.

Care Pathways in a Suicide Crisis Assessment Nurse (SCAN) service

AIM

The Suicide Crisis Assessment Nurse service has been developed as a Primary Care suicide intervention over the last decade. The current study aimed to describe the demographic details of users of this nurse led service, and to evaluate subsequent care pathways following this intervention.

METHODS

This study was conducted using a retrospective file review with a cross-sectional observational design investigating demographic details of service users and care pathways in a Suicide Crisis Assessment Nurse service within a defined catchment area of Ireland between June 2015 and May 2017.

RESULTS

The majority of referrals were managed in Primary Care following Suicide Crisis Assessment Nurse intervention. There was an increase in Primary Care management pathway in the second year of the service which was independent of age and gender.

CONCLUSION

There was an increase in referrals to the service over time, and the majority of presentations were managed in primary care following Suicide Crisis Assessment Nurse intervention. The study suggests that primary care interventions for suicidal crises merit further research.

Towards an Explanatory Model of Suicidal Ideation: The Effects of Cognitive Emotional Regulation Strategies, Affectivity and Hopelessness

Suicide constitutes a public health problem that has a significant economic, social and psychological impact on a global scale. Recently, the American Psychological Association has indicated that suicide prevention should be a public health priority. Suicidal ideation appears as a key variable in suicide prevention. The objective of this research was to verify the adjustment of an explanatory model for suicidal ideation, which considers the effects of cognitive emotion regulation strategies, affectivity and hopelessness. An open mode on-line sample of 2,166 Argentine participants was used and a path analysis was carried out. The results make it possible to conclude that the model presents an optimal fit (χ2 = .10, p = .75, CFI = .99, RMSEA = .01) and predicts 42% of suicidal thoughts. The model proves to be invariant based on age and gender. In conclusion, there is an importance of reducing the use of automatic strategies, such as repetitive negative thoughts of ruminative type, and increasing the use of more controlled strategies, such as reinterpretation or planning.

Hospital-presenting self-harm and ideation: Comparison of incidence, profile and risk of repetition

OBJECTIVE

The aim of this study was to describe presentations to hospital as a result of self-harm or suicidal ideation and to examine patterns of repetition.

METHOD

Presentations made to hospital emergency departments in Northern Ireland following self-harm and ideation between April 2012 and March 2017 were recorded by the Northern Ireland Registry of Self-harm. Person-based rates per 100,000 were calculated using national population estimates. Risk of repeat attendance to hospital was examined using Kaplan-Meier analyses.

RESULTS

A total of 62,213 presentations to emergency departments following self-harm or with ideation were recorded. The rate of self-harm was more than twice the rate of hospital-presenting ideation. Rates of ideation were higher among men, and both self-harm and ideation rates peaked for girls aged 15-19 and men aged 20-24 years. The cumulative probability of repeat attendance to hospital was higher following ideation (52% after 12 months), primarily because 12% of ideation presentations were followed by a subsequent self-harm presentation, whereas 4% of self-harm presentations were followed by ideation.

CONCLUSIONS

Our findings indicate that hospital presenters with ideation are at high risk of future self-harm. The transition from ideation to suicidal behaviour is important to consider and research could inform effective and early intervention measures.

Assessment of suicidal behavior in dermatology (Review)

Many diseases that affect physical health can also affect mental health. Many of these diseases are studied in terms of quality of life, depression and suicidal behavior. Dermatological disorders, although having a strong impact on the individual's life, are less studied with regard to suicidal behavior. There is a need to approach several dermatological diseases from the perspective of suicidal behavior in order to intervene early with specific treatment or to prevent suicide. Psoriasis, acne, melanoma, atopic dermatitis and urticaria are scarcely studied from the point of view of suicidal behavior. In addition to these diseases, there are others that require attention in terms of suicidal behavior, such as vitiligo or oculocutaneous albinism, most probably due to a small number of people suffering from these diseases, research is almost non-existent in these cases. We want to draw attention to the importance of early detection of suicidal behavior in dermatological practice and to highlight the need for several studies on this subject.

Suicide and suicide risk

Although recent years have seen large decreases in the overall global rate of suicide fatalities, this trend is not reflected everywhere. Suicide and suicidal behaviour continue to present key challenges for public policy and health services, with increasing suicide deaths in some countries such as the USA. The development of suicide risk is complex, involving contributions from biological (including genetics), psychological (such as certain personality traits), clinical (such as comorbid psychiatric illness), social and environmental factors. The involvement of multiple risk factors in conveying risk of suicide means that determining an individual's risk of suicide is challenging. Improving risk assessment, for example, by using computer testing and genetic screening, is an area of ongoing research. Prevention is key to reduce the number of suicide deaths and prevention efforts include universal, selective and indicated interventions, although these interventions are often delivered in combination. These interventions, combined with psychological (such as cognitive behavioural therapy, caring contacts and safety planning) and pharmacological treatments (for example, clozapine and ketamine) along with coordinated social and public health initiatives, should continue to improve the management of individuals who are suicidal and decrease suicide-associated morbidity.

Editorial: Suicide and self-harm: advancing from science to preventing deaths

Globally, suicide is the second leading cause of death among youth ages 15-29-years, and self-harm is one of the strongest known predictors of death by suicide. This editorial introduces the Special Issue on suicide and self-harm, emphasizing the research and policy implications of the included articles. By illustrating advances in our science, the Special Issue both celebrates our achievements and highlights the need to use our science to inform suicide prevention policy and practice to reduce the tragedy of suicide and premature deaths.

Distinguishing suicide ideation from suicide attempts: Further test of the Integrated Motivational-Volitional Model of Suicidal Behaviour

Suicidal behaviour poses a significant public health concern. Research into the factors that distinguish between the emergence of suicide ideation and the enactment of a suicide attempt is crucial. This study tests central tenets of the Integrated Motivational-Volitional Model of suicidal behaviour (IMV, O'Connor and Kirtley, 2018) which posits that volitional phase factors govern the transition from thinking to attempting suicide. 299 adults completed a face-to-face interview and were allocated to groups based on their suicidal history: Suicide attempt group (N = 100), suicide ideation group (N = 105), and a control group (N = 94). Measures were taken at baseline, at 1-month and 6-months follow-up. As predicted, the attempt group differed from the ideation group on all volitional phase factors. Those who had attempted suicide reported higher capability for suicide, were more likely to have a family member or friend who had self-injured or attempted suicide, and were more impulsive. In keeping with the IMV model, the ideation and attempt groups had similar scores on the motivational factors. Defeat and entrapment were significant predictors of ideation at baseline, and mediation analyses indicated that defeat had an indirect effect on ideation through entrapment at baseline and at 1-month follow-up. The results support the IMV model and suggest that entrapment should be routinely included in suicide risk assessments. Further research to test predictors of the transition from suicide ideation to suicide attempts is crucial to inform future intervention development and health care delivery.

Suicide prevention: Putting the person at the center

In September's Editorial, Vikram Patel and Pattie Gonsalves discuss suicide prevention, the focus of World Mental Health Day, 2019.

Suicide Mortality in Foreign Residents of Japan

Suicide is a major public health issue in Japan, with very high rates of death compared to other countries in the Asia Pacific. Foreigners living in Japan may be at increased risk of suicide, but little is known about how their risk of suicide differs from that of their country of origin or Japanese nationals. We used data on suicide mortality from the Japan Vital Registration System for the period 2012–2016 to analyze risk of suicide mortality in Japan for Japanese, Korean, Chinese, and other nationalities living in Japan, adjusting for age and separately by sex. We estimated standardized mortality rates using both the Japanese population as a reference, and also the population of the home nation of the foreign residents. We found that Korean nationals living in Japan have significantly higher mortality rates than Japanese nationals, and that the suicide mortality rate of Korean nationals living in Japan is higher than in their home country, but that this is not the case for Chinese or other nationals resident in Japan. Koreans living in Japan have a very high risk of mortality due to suicide which may reflect the special social, economic, and cultural pressures they face as a marginalized population in Japan.

Risk factors associated with suicide among kidney cancer patients: A Surveillance, Epidemiology, and End Results analysis

Background

The suicide risk was higher in kidney cancer patients than in the general population. The purpose of this study was to characterize the suicide rates among kidney cancer patients and to identify the potential risk factors associated with suicide from the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

Kidney cancer patients were identified from the SEER database during 1973‐2015. Suicide rates and standardized mortality ratios (SMRs) of this population were calculated, and the US general population during 1981‐2015 was chosen as a reference. Univariable and multivariable Cox regression were performed to find out potential risk factors of suicide.

Results

There were 207 suicides identified among 171 819 individuals with kidney cancer observed for 948 272 person‐years. The suicide rate was 21.83 per 100 000 person‐years, and SMR was 1.83 (95% CI: 1.59‐2.10). On Cox regression, diagnosis in early years (1973‐1982 vs 2003‐2015, HR: 2.03, 95% CI: 1.01‐4.11, P = 0.048; 1983‐1992 vs 2003‐2015, HR: 1.99, 95% CI: 1.18‐3.35, P = 0.010), male sex (vs female sex, HR: 4.43, 95% CI: 2.95‐6.65, P < 0.001), unmarried status (vs married status, HR: 2.54, 95% CI: 1.91‐3.38, P < 0.001), non‐black race (white race vs black race, HR: 4.47, 95% CI: 2.09‐9.58, P < 0.001; other races vs black race, HR: 3.01, 95% CI: 1.08‐8.37, P = 0.035), higher histologic grade (grade IV vs grade I, HR: 3.27, 95% CI: 1.50‐7.13, P = 0.003; grade III vs grade I, HR: 2.13, 95% CI: 1.19‐3.81, P = 0.011) and cancer‐directed surgery not performed (vs performed, HR: 2.78, 95% CI: 1.52‐5.11, P < 0.001) were independent risk factors of suicide among kidney cancer patients.

Conclusions

Diagnosis in early years, male sex, unmarried status, non‐black race, higher histologic grade, and cancer‐directed surgery not performed were significantly associated with suicide among kidney cancer patients. In order to prevent suicidal death, clinicians should pay more attention to patients with high‐risk factors of suicide.