Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review

Psychosocial and psychiatric factors preceding death by suicide: A case-control psychological autopsy study involving multiple data sources

BACKGROUND

A range of factors including mental disorders and adverse life events can increase the risk of suicide. The objectives of this study were to examine psychosocial and psychiatric factors and service engagement among suicide decedents compared with living controls.

METHODS

A case-control study using multiple sources was conducted. Information on 132 consecutive cases of suicide was drawn from coronial files, and interviews were carried out with 35 family informants and 53 living controls. GPs completed questionnaires for 60 suicide cases and 27 controls.

RESULTS

The majority (83.3%) of suicide decedents had contacted a GP in the year prior to death, while 23.3% had 10 or more consultations during the year prior to death. Half of suicide decedents had a history of self-harm. Suicide cases were significantly more likely than controls to have a psychiatric diagnosis (60% vs. 18.5%) and a depressive illness (36.7% vs. 14.8%). Over one-quarter of suicide decedents had been treated as a psychiatric inpatient.

DISCUSSION

Primary care providers should be supported to deliver multidisciplinary interventions to engage, assess, and treat patients at risk of suicide, targeting those who present very frequently, those with a history of self-harm or substance misuse, and those with psychological presentations.

The feasibility of using smartphone apps as treatment components for depressed suicidal outpatients

Mental health smartphone apps could increase the safety and self-management of patients at risk of suicide, but it is still unclear whether it is feasible to integrate such apps into routine mental healthcare. This study reports on the feasibility of using a safety planning app (BackUp) and a self-monitoring app (mEMA) as components of the routine treatment of depressed outpatients with suicidal ideation. Clinicians were trained in working with both of the apps, and they invited their eligible patients with suicidal ideation for study participation. Patients used the apps for 3 months and discussed these with their clinician during treatment. Patients completed assessments at baseline (T0), 4 weeks (T1) and post-test (T2, 12 weeks after baseline). Both patients and clinicians also participated in telephone interviews. Feasibility was assessed in terms of usability (score > 70 on System Usability Scale, SUS), acceptability (score > 20 on Client Satisfaction Questionnaire-8, CSQ-8), and uptake (sufficient rates of component completion and app usage in treatment). The sample included 17 adult outpatients (52.9% male, age range 20-50 years) diagnosed with a depressive disorder and suicidal ideation at baseline. BackUp was rated by patients at above the cut-off scores for usability (SUS mean score at T1 75.63 and at T2 77.71) and acceptability (CSQ-8 mean score at T1 23.42 and at T2 23.50). mEMA was similarly rated (SUS mean score at T1 75.83 and at T2 76.25; CSQ-8 mean score at T1 23.92 and at T2 22.75). Telephone interviews with patients and clinicians confirmed the usability and acceptability. The uptake criteria were not met. Our findings suggest that mobile safety planning and mobile self-monitoring can be considered acceptable and usable as treatment components for depressed suicidal outpatients, but the integration of apps into routine treatment needs to be further explored.

Smartphone-based Ecological Momentary Intervention for secondary prevention of suicidal thoughts and behaviour: protocol for the SmartCrisis V.2.0 randomised clinical trial

INTRODUCTION

Suicide is one of the leading public health issues worldwide. Mobile health can help us to combat suicide through monitoring and treatment. The SmartCrisis V.2.0 randomised clinical trial aims to evaluate the effectiveness of a smartphone-based Ecological Momentary Intervention to prevent suicidal thoughts and behaviour.

METHODS AND ANALYSIS

The SmartCrisis V.2.0 study is a randomised clinical trial with two parallel groups, conducted among patients with a history of suicidal behaviour treated at five sites in France and Spain. The intervention group will be monitored using Ecological Momentary Assessment (EMA) and will receive an Ecological Momentary Intervention called 'SmartSafe' in addition to their treatment as usual (TAU). TAU will consist of mental health follow-up of the patient (scheduled appointments with a psychiatrist) in an outpatient Suicide Prevention programme, with predetermined clinical appointments according to the Brief Intervention Contact recommendations (1, 2, 4, 7 and 11 weeks and 4, 6, 9 and 12 months). The control group would receive TAU and be monitored using EMA.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of the University Hospital Fundación Jiménez Díaz. It is expected that, in the near future, our mobile health intervention and monitoring system can be implemented in routine clinical practice. Results will be disseminated through peer-reviewed journals and psychiatric congresses. Reference number EC005-21_FJD. Participants gave informed consent to participate in the study before taking part.

TRIAL REGISTRATION NUMBER

NCT04775160.

Population- and Community-Based Interventions to Prevent Suicide

Background: Suicide is estimated to account for 1.4% of deaths worldwide, making it among the leading causes of premature death. Public health approaches to reduce suicide have the potential to reach individuals across the spectrum of suicide risk. Aims: To review the effectiveness of newer community-based or population-level suicide prevention strategies. Methods: We conducted a systematic review of literature published from January 2010 to November 2020 to evaluate the effectiveness of community- and population-level interventions. The US Center for Disease Control framework was used for grouping studies by strategy. Results: We included 56 publications that described 47 unique studies. Interventions that reduce access to lethal means, implement organizational policies and culture in police workplace settings, and involve community screening for depression may reduce suicide deaths. It is unclear if other interventions such as public awareness and education campaigns, crisis lines, and gatekeeper training prevent suicide. Evidence was inconsistent for community-based, multistrategy interventions. The most promising multistrategy intervention was the European Alliance Against Depression. Limitations: Most eligible studies were observational and many lacked concurrent control groups or adjustment for confounding variables. Conclusions: Community-based interventions that may reduce suicide deaths include reducing access to lethal means, implementing organizational policies in workplace settings, screening for depression, and the multistrategy European Alliance Against Depression Program. Evidence was unclear, inconsistent, or lacking regarding the impact of many other single- or multistrategy interventions on suicide deaths.

Relationship between burnout and Major Depressive Disorder in health professionals: A HEAR report

BACKGROUND

Burnout is a "normal" albeit concerning response to workplace stress, whereas Major Depressive Disorder (MDD) is a serious illness associated with impairment and suicide risk. Because of symptomatic overlap between the two conditions and MDD-associated stigma, individuals reporting work-related stress and depression often are "diagnosed" with burnout at the expense of recognizing and treating MDD. Our study aimed to leverage organizational implementation of the American Foundation of Suicide Prevention's Interactive Screening Program to elucidate relationships among burnout, depression, and other suicide risk factors.

METHODS

2281 of about 30,000 (~7.6 %) medical trainees, staff, and faculty responded to an anonymous online stress and depression questionnaire. Respondents were grouped into four cohorts: screened positive for burnout alone (n = 439, 19 %), depression alone (n = 268, 12 %), both conditions (n = 759, 33 %), or neither condition (n = 817, 36 %), and compared on multiple measures of distress and other suicide risk factors.

RESULTS

Burnout alone and depression alone each predicted greater distress and suicide risk compared with neither condition. Depression was a stronger predictor than burnout and demonstrated a consistent association with other suicide risk factors regardless of whether burnout was present. In contrast, burnout was not consistently associated with other suicide risk factors when depression was present.

LIMITATIONS

The sample was limited to one state-supported academic medical center; to individuals who elected to take the online survey; and relied on a single item, non-validated measure of burnout.

CONCLUSION

When emotional distress is reported by healthcare workers, attention should not stop at "burnout," as burnout frequently comingles with clinical depression, a serious and treatable mental health condition.

Arketamine, a new rapid-acting antidepressant: A historical review and future directions

The N-methyl-d-aspartate receptor (NMDAR) antagonist (R,S)-ketamine causes rapid onset and sustained antidepressant actions in treatment-resistant patients with major depressive disorder (MDD) and other psychiatric disorders, such as bipolar disorder and post-traumatic stress disorder. (R,S)-ketamine is a racemic mixture consisting of (R)-ketamine (or arketamine) and (S)-ketamine (or esketamine), with (S)-enantiomer having greater affinity for the NMDAR. In 2019, an esketamine nasal spray by Johnson & Johnson was approved in the USA and Europe for treatment-resistant depression. In contrast, an increasing number of preclinical studies show that arketamine has greater potency and longer-lasting antidepressant-like effects than esketamine in rodents, despite the lower binding affinity of arketamine for the NMDAR. Importantly, the side effects, i.e., psychotomimetic and dissociative effects and abuse liability, of arketamine are less than those of (R,S)-ketamine and esketamine in animals and humans. An open-label study demonstrated the rapid and sustained antidepressant effects of arketamine in treatment-resistant patients with MDD. A phase 2 clinical trial of arketamine in treatment-resistant patients with MDD is underway. This study was designed to review the brief history of the novel antidepressant arketamine, the molecular mechanisms underlying its antidepressant actions, and future directions.

What Are Complex Interventions in Suicide Research? Definitions, Challenges, Opportunities, and the Way Forward

It has been argued that effective action towards addressing a complex concern such as suicide requires a combination of evidence-based strategies. While these complex public health approaches have recently gained importance, little is known about their characteristics and what contributes to their complexity. The use of interchangeable terms such as multilevel, multicomponent, community based, and inconsistent definitions of these approaches creates confusion around what it is and what it is not. In practice, this disorder is reflected in a substantial variation in the design, implementation, and evaluation of complex approaches in suicide research. While it is impossible to resolve all existing inconsistencies in terminology, this review explores a range of terms and definitions to connote complex interventions. It aims to unpack multiple meanings of these terms and their diverse usage in suicide literature. The potential implications of this fluidity and plausible pathways to make sense of this complexity for suicide research are also discussed. With a shared understanding of what constitutes a complex intervention, we can expect to see an improved representation of the real-world complexities in our efforts to address suicide. This common language can also contribute toward quality implementation and dissemination and thereby advance our understanding of complex interventions.

Analysis of Attempted Suicide in a Pediatric Setting: Extracted Notes for Clinical Practice and Complexity of Help

Background and Objectives: Suicidality among adolescents is a global mental health issue. However, the post-suicidal care of minors is insufficient and lacks complexity, as repeated attempts occur. Further, little is known about the social (i.e., family setting) and psychological (for example, exposure to bullying, suicidality, or addiction within a close environment) backgrounds of minors who engage in suicidal behavior in Lithuania. Thus, the aim of our study was to evaluate and compare psychosocial factors that may influence minors’ decisions to attempt suicide for the first time and then repeatedly and to extract notes for future clinical practice. Materials and Methods: Data from 187 cases of suicide attempts by minors treated at the Children’s Hospital of Vilnius University Santara Clinics from January 2011 to January 2018 was obtained and analyzed. Results: The data showed that 48.7% of minors hospitalized because of a suicide attempt had a history of previous suicide attempts. Minors who attempted suicide repeatedly were more often engaged in non-suicidal self-injurious behavior (p = 0.033). Further, a small number had experienced suicide within their close surroundings (p = 0.045). The comparative analysis did not reveal any significant differences in psychosocial backgrounds between first-time attempters and those who attempted suicide for at least a second time. Conclusions: Social and psychological support after a suicide attempt in a pediatric setting is lacking efficiency, as minors who repeatedly attempt suicide suffer from similar psychosocial burdens. Complex and targeted follow-up care is needed.

Structural Racism and Suicide Prevention for Ethnoracially Minoritized Youth: A Conceptual Framework and Illustration Across Systems

Suicide rates among ethnoracially minoritized youth (i.e., youth of color) peak before the age of 30, and striking disparities in access to mental health services have been identified in this age group. However, suicide prevention strategies have yet to fully address structural racism as a mechanism in producing disparities in risk, protective factors, and access to quality effective intervention for youth of color. Such an approach is critical to provide more culturally responsive mental health care. Through an adapted socio-ecological model, the authors propose the Structural Racism and Suicide Prevention Systems Framework and illustrate pathways through which structural racism impacts suicide prevention and intervention for youth of color in the United States. The authors contextualize the impact of structural racism in three key settings where youth suicide prevention occurs: mental health services, schools, and the interface between crisis care and law enforcement. The authors posit that critical attention must be paid to the intersection of mutually reinforcing, interdependent systems rather than to systems in isolation. The authors then propose recommendations to address structural racism in suicide prevention, including macro-level interventions to improve societal conditions, research strategies to inform structural solutions, training approaches to address institutional racism, and clinical approaches to address the impact of racism and racial trauma on youths and families.

A Novel Recovery-Based Suicide Prevention Program in Upstate New York

Suicide prevention efforts have focused primarily on screening, education, and brief interventions rather than on treatment of underlying vulnerabilities. The Psychiatry High Risk Program (PHRP) is a specialized outpatient program for suicidal youths and young adults that facilitates transitions in care and provides comprehensive treatment aimed at healing and recovery. The authors evaluated the program's impact on inpatient utilization and suicide risk for patients (N=32) who were referred to the PHRP after psychiatric hospitalization for suicidality. Results indicate that program participants had large reductions in depression and suicidal ideation over 180 days postdischarge; they also had significantly fewer rehospitalizations than did a matched historical cohort, with an average savings of >6 hospital days per patient. These preliminary results suggest that a recovery-based suicide prevention program can be feasible and sustainable and may be cost-effective in a value-based system of care.

Suicide Prevention Interventions and Their Linkages in Multilayered Approaches for Older Adults: A Review and Comparison

Multilayered approaches to suicide prevention combine universal, selective, and indicated prevention interventions. These approaches may be more successful in reducing suicide rates among older adults if they link these layers more systematically: that is, if the programs are designed so that interventions at a lower level facilitate involvement at a higher level when appropriate. This study aimed to examine the effect on suicide rates of the structure of multilayered approaches, and in particular the types of interventions and the connections or linkages between them. We also wished to consider any different effects by sex. A literature search used PubMed and PsycINFO to identify systematic reviews of interventions in this age group. From the reference lists of these articles, we identified controlled studies assessing the impact of a multilayered program on suicide incidence among older adults. We were particularly interested in initiatives linking different kinds of prevention interventions. We found three relevant systematic reviews, and from these, we identified nine eligible studies. These included seven non-randomized controlled studies from rural areas in Japan (average eligible population: 3,087, 59% women, average duration: 8 years). We also found two cohort studies. The first was from a semi-urban area in Padua, Italy (18,600 service users, 84% women, duration: 11 years). The second was from urban Hong Kong, with 351 participants (57% women) over a 2-year follow-up period. We used a narrative synthesis of these studies to identify five different multilayered programs with different forms of connections or linkages between layers. Two studies/programs (Italy and Hong Kong) involved selective and indicated prevention interventions. One study/program (Yuri, Japan) included universal and selective prevention interventions, and the final six studies (two programs in northern Japan) involved linkages between all three layers. We also found that these linkages could be either formal or informal. Formal linkages were professional referrals between levels. Informal linkages included advice from professionals and self-referrals. Several of the studies noted that during the program, the service users developed relationships with services or providers, which may have facilitated movements between levels. All five programs were associated with reduced suicide incidence among women in the target groups or communities. Two programs were also associated with a reduction among men. The study authors speculated that women were more likely to accept services than men, and that the care provided in some studies did less to address issues that are more likely to affect men, such as suicidal impulsivity. We therefore suggest that it is important to build relationships between levels, especially between selective and indicated prevention interventions, but that these can be both formal and informal. Additionally, to reach older men, it may be important to create systematic methods to involve mental health professionals in the indicated prevention intervention. Universal interventions, especially in conjunction with systematically linked indicated and selective interventions, can help to disseminate the benefits across the community.

Risk and Protective Factors Associated with Suicidal Thoughts and Behaviors Among Maryland Middle School Students

The aim of this study was to identify independent risk and protective factors associated with self-reported suicidal thoughts and behaviors (STB) among young adolescents by examining self-report data on mental health, substance abuse, violence involvement, social and economic challenges and supports, physical health and demographics in relation to STB. Data from nearly 27,000 students who completed the 2018-19 Maryland Middle School Youth Risk Behavior Survey/Youth Tobacco Survey (YRBS/YTS) were used to identify independent risk and protective factors associated with STB among middle school students (grades 6–8; ages 11-14). Twenty-three percent of students reported lifetime suicidal ideation and nine percent reported lifetime attempt(s). Independent risk factors associated with STB include depression, substance abuse or misuse, violence involvement, bullying victimization at school or electronically, sexual activity, and sleep deprivation. Protective factors include having an adult outside of school to confide in and feeling that teachers care and provide encouragement. Interactive effects by gender and/or race/ethnicity were observed for some factors in relation to STB. These results suggest that evidence-based programs and policies at the universal and selective/indicated levels in school settings are needed and should be introduced earlier on to address the widespread prevalence of STB in young adolescents. Program planners should take into consideration social, cultural and language needs when implementing and developing intervention strategies.

Improving Suicide Prevention in Primary Care for Differing Levels of Behavioral Health Integration: A Review

Importance

Suicide prevention implementation in primary care is needed due to the increasing rate of suicide in the past few decades, particularly for young and marginalized people. Primary care is the most likely point of contact for suicidal patients in the healthcare system. Attention to the level of medical integration with behavioral health is vital to suicide prevention and is applied throughout this review.

Methods

A narrative review was performed.

Observations

Many interventions help improve suicide prevention care. PCP education, screening, safety planning/lethal means reduction, care transitions, psychotherapy, and medication management are all evidence-based strategies. Additionally, the pragmatic topics of financing suicide prevention, supporting providers, enacting suicide postvention, and preparing for future directions in the field at each level of primary care/behavioral health integration are discussed.

Conclusions and Relevance

The findings are clinically relevant for practices interested in implementing evidence-based suicide prevention strategies by attending to the behavioral health/medical interface. Leveraging the patient/provider relationship to allow for optimal suicide prevention care requires clinics to structure provider time to allow for emotionally present care. Defining clear roles for staff and giving attention to provider well being are also critical factors to supporting primary care-based suicide prevention efforts.

Suicide and self-harm

Suicide and self-harm are major health and societal issues worldwide, but the greatest burden of both behaviours occurs in low-income and middle-income countries. Although rates of suicide are higher in male than in female individuals, self-harm is more common in female individuals. Rather than having a single cause, suicide and self-harm are the result of a complex interplay of several factors that occur throughout the life course, and vary by gender, age, ethnicity, and geography. Several clinical and public health interventions show promise, although our understanding of their effectiveness has largely originated from high-income countries. Attempting to predict suicide is unlikely to be helpful. Intervention and prevention must include both a clinical and community focus, and every health professional has a crucial part to play.

Preventing male suicide through a psychosocial intervention that provides psychological support and tackles financial difficulties: a mixed method evaluation

BACKGROUND

To help resolve high suicide rates in Bristol, North Somerset and South Gloucestershire, the charity Second Step was commissioned to roll-out the Hope service offering a psychosocial intervention for men, supporting them through acute distress and addressing financial difficulties. This study evaluated the impact of the Hope service on men at risk of suicide experiencing financial and other difficulties.

METHODS

Mixed methods study using: (i) a prospective cohort study design to compare depression, suicidal ideation and financial self-efficacy scores of men aged 30-64, referred to the service between October 2018 and July 2020, at baseline and 6 months follow-up and between low and moderate to high-intensity service users; and (ii) a qualitative interview study to evaluate the acceptability and impact of the Hope service to Hope service users.

RESULTS

There was a 49% reduction in depression score (mean reduction - 10.0, 95% CI - 11.7 to - 8.3) and in the proportion of service users with suicidal ideation (percent reduction - 52.5, 95% CI - 64.1% to - 40.9%) at 6 months follow-up compared to baseline. Financial self-efficacy scores increased by 26% (mean increase 2.9, 95% CI 1.8 to 3.9). Qualitative accounts illustrated how 'Hope saved my life' for several men interviewed; most respondents described being able to move forward and tackle challenges with more confidence following the Hope intervention. Professional advice to tackle financial and other difficulties such as housing helped to relieve anxiety and stress and enable practical issues to be resolved.

CONCLUSIONS

The Hope service offered practical and emotional support to men who have experienced suicidal feelings, redundancy, homelessness and poverty and occupies an important space between mental health and social care provision. Hope demonstrates the value of an intervention which cuts across traditional boundaries between psychiatric care and social advice agencies to provide, what is, in effect, an integrated care service.

Real-world feasibility and acceptability of real-time suicide risk monitoring via smartphones: A 6-month follow-up cohort

Active and passive Ecological Momentary Assessment of suicide risk is crucial for suicide prevention. We aimed to assess the feasibility and acceptability of active and passive smartphone-based EMA in real-world conditions in patients at high risk for suicide. We followed 393 patients at high risk for suicide for six months using two mobile health applications: the MEmind (active) and the eB2 (passive). Retention with active EMA was 79.3% after 1 month and 22.6% after 6 months. Retention with passive EMA was 87.8% after 1 month and 46.6% after 6 months. Satisfaction with the MEmind app, uninstalling the eB2 app and diagnosis of eating disorders were independently associated with stopping active EMA. Satisfaction with the eB2 app and uninstalling the MEmind app were independently associated with stopping passive EMA. Smartphone-based active and passive EMA are feasible and may increase accessibility to mental healthcare.

The effect of social network strain on suicidal ideation among middle-aged adults with adverse childhood experiences in the US: A twelve-year nationwide study

Objective

Building on literature that measured the association between social network strain (SNS) and suicidal ideation using conventional regression analyses, we examined the effect of SNS, due to adverse childhood experiences (ACEs), on suicidal ideation using instrumental variables (IV) to eliminate the potential biases that may have occurred in earlier studies due to residual confounding.

Methods

This retrospective cohort study linked longitudinal data from the National Survey of Midlife Development in the United States (MIDUS) Refresher Biomarker Project (2012–2016), the MIDUS Refresher Project (2011–2014), the MIDUS 2 Biomarker Project (2004–2009), and the MIDUS 2 Project (2004–2006). Participants completed a phone interview, self-administered survey, and biomarker data collection. Exposure indicators included self-reported suicidal ideation, ACEs, and SNS from family, spouse, and friends. IV analysis was used to evaluate the continuous local average treatment effect of SNS on suicidal ideation when SNS only varied due to variation in ACEs.

Results

Our sample included 1703 middle-aged adults (52.9% females), which were followed up for 12 years. An IV probit model controlling for sociodemographic characteristics found a one-standard-deviation reduction in SNS reduced suicidal ideation by 22.6% (p < 0.01). A comprehensively controlled IV probit model found that a one-standard-deviation reduction in SNS is associated with a 21.4% (p = 0.05) decrease in suicidal ideation.

Conclusions

The causal pathway from SNS (due to ACEs) to suicidal ideation among middle-aged adults was established using IV analysis in this large-scale longitudinal study. The magnitude of this effect is sufficient to warrant the development of programs to improve social network relationships among family, friends, and spouses/partners. Suicide prevention programs addressing SNS may significantly reduce suicidal ideation among middle-aged Americans who have experienced ACEs.

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Social Network Strain (SNS) from family, spouse, and friends is common.

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SNS derives from demands, criticisms, disappointments, and irritations.

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SNS varies strongly with Adverse Childhood Experiences (ACEs).

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Reductions in SNS due to fewer ACEs decrease suicidal ideation.

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A one standard-deviation reduction in SNS lowers suicidal ideation by 20%.

Ketamine for suicidality: an umbrella review

The urgent need for appropriate treatment for suicide, the tenth leading cause of death, has led to numerous studies. This study aims to systematically identify and appraise systematic reviews with or without meta-analyses investigating ketamine in suicidal ideation and behaviors. The study protocol was published in PROSPERO (CRD42021285320). Scopus, ISI, Embase, PubMed, CINAHL, PsycINFO, Cochrane Library, Google Scholar, and two registries were searched on October 29 without any restrictions for systematic reviews investigating the efficacy of ketamine on suicidal ideation and behaviors. The primary outcome was the final inference of ketamine effectiveness. A formal narrative synthesis was conducted, and the AMSTAR-2 tool was used to evaluate the quality of the studies. No funding was received. Of 27 studies that addressed ketamine for suicidal ideation, only four reported mixed or negative results, and out of nine reviews, esketamine was significantly beneficial only in five. A transient rise in pulse rate and blood pressure, dissociation, confusion, blurred vision, nausea, and vertigo were of the most common adverse effects; however, most were mild. More than two-thirds of the included studies qualified as low or critically low quality. Preliminary evidence for the short-term efficacy of ketamine in suicidality was noted by the majority of reviews; however, long-term effects remained unknown. Due to the non-high quality of many studies and the limitations of core studies, further studies are required.

Predicting suicide attempts among U.S. Army soldiers after leaving active duty using information available before leaving active duty: results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS)

Suicide risk is elevated among military service members who recently transitioned to civilian life. Identifying high-risk service members before this transition could facilitate provision of targeted preventive interventions. We investigated the feasibility of doing this by attempting to develop a prediction model for self-reported suicide attempts (SAs) after leaving or being released from active duty in the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). This study included two self-report panel surveys (LS1: 2016-2018, LS2: 2018-2019) administered to respondents who previously participated while on active duty in one of three Army STARRS 2011-2014 baseline self-report surveys. We focus on respondents who left active duty >12 months before their LS survey (n = 8899). An ensemble machine learning model using predictors available prior to leaving active duty was developed in a 70% training sample and validated in a 30% test sample. The 12-month self-reported SA prevalence (SE) was 1.0% (0.1). Test sample AUC (SE) was 0.74 (0.06). The 15% of respondents with highest predicted risk included nearly two-thirds of 12-month SAs and over 80% of medically serious 12-month SAs. These results show that it is possible to identify soldiers at high post-transition self-report SA risk before the transition. Future model development is needed to examine prediction of SAs assessed by administrative data and using surveys administered closer to the time of leaving active duty.

Prevalence of Firearm Ownership Among Individuals With Major Depressive Symptoms

IMPORTANCE

Both major depression and firearm ownership are associated with an increased risk for death by suicide in the United States, but the extent of overlap among these major risk factors is not well characterized.

OBJECTIVE

To assess the prevalence of current and planned firearm ownership among individuals with depression.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional survey study using data pooled from 2 waves of a 50-state nonprobability internet survey conducted between May and July 7, 2021. Internet survey respondents were 18 years of age or older and were sampled from all 50 US states and the District of Columbia.

MAIN OUTCOMES AND MEASURES

Self-reported firearm ownership; depressive symptoms as measured by the 9-item Patient Health Questionnaire.

RESULTS

Of 24 770 survey respondents (64.6% women and 35.4% men; 5.0% Asian, 10.8% Black, 7.5% Hispanic, and 74.0% White; mean [SD] age 45.8 [17.5]), 6929 (28.0%) reported moderate or greater depressive symptoms; this group had mean (SD) age of 38.18 (15.19) years, 4587 were female (66.2%), and 406 were Asian (5.9%), 725 were Black (10.5%), 652 were Hispanic (6.8%), and 4902 were White (70.7%). Of those with depression, 31.3% reported firearm ownership (n = 2167), of whom 35.9% (n = 777) reported purchasing a firearm within the past year. In regression models, the presence of moderate or greater depressive symptoms was not significantly associated with firearm ownership (adjusted odds ratio [OR], 1.07; 95% CI, 0.98-1.17) but was associated with greater likelihood of a first-time firearm purchase during the COVID-19 pandemic (adjusted OR, 1.77; 95% CI, 1.56-2.02) and greater likelihood of considering a future firearm purchase (adjusted OR, 1.53; 95% CI, 1.23-1.90).

CONCLUSIONS AND RELEVANCE

In this study, current and planned firearm ownership was common among individuals with major depressive symptoms, suggesting a public health opportunity to address this conjunction of suicide risk factors.

National Trends of Mental Health Care Among US Adults Who Attempted Suicide in the Past 12 Months

IMPORTANCE

Although suicide attempts remain the strongest risk factor for future suicide, little is known about recent trends in the prevalence of and risk factors for suicide attempts and past-year use of services among adults who attempted suicide.

OBJECTIVE

To estimate annual rates of suicide attempts and use of mental health services among US adults from 2008 to 2019.

DESIGN, SETTING, AND PARTICIPANTS

This US nationally representative cross-sectional study used the National Survey of Drug Use and Health (NSDUH) from 2008 through 2019. Participants included noninstitutionalized US civilians 18 years or older (n = 484 732). The overall annual rates of suicide attempts per 100 000 adults in the general population and national trends from 2008 to 2019 were estimated, with suicide attempts defined as self-reported efforts to kill one's self in the past 12 months. Subgroup analyses were also performed by demographic characteristics and clinical conditions. The trends in past-year use of mental health services among those who reported past-year suicide attempts were then examined. Data were analyzed from October to December 2021.

MAIN OUTCOMES AND MEASURES

Rate of suicide attempts from 2008 to 2019. Multivariate-adjusted logistic regression analyses were used to determine whether adjusting for sociodemographic and clinical factors associated with past-year suicide attempts could account for the change within the study period.

RESULTS

Of 484 732 survey participants, most were 35 years or younger (69.8%), women (51.8%), and non-Hispanic White individuals (65.7%). From 2008 to 2019, the weighted unadjusted suicide attempt rate per 100 000 population increased from 481.2 to 563.9 (odds ratio [OR], 1.17 [95% CI, 1.01-1.36]; P = .04) and remained significant after controlling for sociodemographic characteristics (adjusted OR [aOR], 1.23 [95% CI, 1.05-1.44]; P = .01). Rates of suicide attempt increased particularly among young adults aged 18 to 25 years (aOR, 1.81 [95% CI, 1.52-2.16]; P < .001), women (aOR, 1.33 [95% CI, 1.09-1.62]; P = .005), those who were unemployed (aOR, 2.22 [95% CI, 1.58-3.12]; P < .001) or never married (aOR, 1.60 [95% CI, 1.31-1.96]; P < .001), and individuals who used substances (aOR, 1.44 [95% CI, 1.19-1.75]; P < .001). In multivariate analyses, the temporal trend of increasing suicide attempts remained significant even after controlling for other significant sociodemographic and clinical factors (aOR, 1.36 [95% CI, 1.16-1.60]; P < .001). Several sociodemographic and clinical subgroups remained independently associated with suicide attempts, especially those with serious psychological distress (aOR, 7.51 [95% CI, 6.49-8.68]; P < .001), major depressive episodes (aOR, 2.90 [95% CI, 2.57-3.27]; P < .001), and alcohol use disorder (aOR, 1.81 [95%CI, 1.61-2.04]; P< .001) as well as individuals who reported being divorced or separated (aOR, 1.65 [95% CI, 1.35-2.02]; P < .001) or being unemployed (aOR, 1.47 [95% CI, 1.27-1.70]; P< .001) and those who identified as Black (aOR, 1.41 [95% CI, 1.24-1.60]; P < .001) or American Indian or Alaska Native, Asian, or Native Hawaiian or Other Pacific Islander (aOR, 1.56 [95% CI, 1.26-1.93]; P < .001). Among adults with a suicide attempt, there was no significant change in the likelihood of receiving past-year mental health or substance-related services. During the study period, 34.8% to 45.5% reported needing services but did not receive them, with no significant change from 2008 to 2019.

CONCLUSIONS AND RELEVANCE

Although suicide attempts appear to be increasing, use of services among those who attempted suicide has not increased, suggesting a need to expand service accessibility and/or acceptability, as well as population-wide prevention efforts.

Motivating Behavior Change in Parents for Suicide Prevention in the Midwest, USA

Safe storage of lethal means is an evidence-based approach to suicide prevention that is underutilized. This naturalistic study investigated whether a presentation on parenting teenagers that includes education about safe storage of firearms and medications, paired with tools to enact change, can impact storage practices. Ten community presentations for parents were given between November 2018 and September 2019 in the Midwest region of the United States. Multiple topics pertinent to parenting adolescents were included with an emphasis on safe storage of firearms and medications to reduce suicide risk. Toolkits including medication storage boxes and cable gun locks were offered to help parents enact recommended changes. Surveys were completed prior to the presentation (T1), immediately following the presentation (T2), and 2 weeks after the presentation (T3). Five-hundred eighty-one parents comprised the initial study sample, of whom 410 (70.6%) completed the primary study endpoint. Generalized linear mixed models with and without worst-case imputation were used to evaluate changes in safe storage practices. Results suggested the odds of storing firearms in the safest manner possible increased 5.9 times (95% CI 2.6-13.5, p < 0.001) without imputation and increased 2.0 times (95% CI 1.1-3.4, p = 0.02) with the worst-case imputation. Among participants with unlocked medications at baseline, 56.5% reported they had disposed of old medications and 53.0% reported locking up bottles of medication by the primary study endpoint. This study provides preliminary evidence that safe storage education paired with tools for behavior change motivates parents to enact safe storage measures.

Criminalisation of suicide and suicide rates: an ecological study of 171 countries in the world

OBJECTIVE

In the last half of the 20th century, many countries have already abolished antisuicide laws; however, more than 20 countries still adopt them. This paper is the first to systematically explore the association between criminalisation of suicide and national suicide rates in 171 countries/regions to examine the deterring effects of the antisuicide laws.

DESIGN

A cross-sectional ecological study.

SETTING

171 countries in the world.

PARTICIPANTS

In 2012, 25 countries were identified to carry antisuicide laws. A linear regression analysis was adopted to explore the association between national suicide rates (log transformed) and criminalisation of suicide in the world in 2012, having controlled for the Human Development Index (HDI), majority religious affiliations and the national unemployment rate.

MAIN OUTCOME MEASURE

Sex-specific age standardised suicide mortality rates.

RESULTS

Criminalisation of suicide was associated with slightly increased national suicide rates (β estimate=0.29, 95% CI -0.04 to 0.61). Stronger association was found in women (β estimate=0.40, 95% CI 0.06 to 0.74), connecting criminalisation of suicide and higher suicide rates. The harmful effect of antisuicide laws on women was particularly prominent in non-Muslim countries and countries with lower HDI.

CONCLUSIONS

Laws penalising suicide were associated with higher national suicide rates and even more so in the female population in the low HDI, non-Muslim countries. The non-supportive patriarchal culture with laws penalising suicide may render women vulnerable to suicidality. Instead of criminalising suicide, alternative approaches such as providing good mental healthcare and adjusting the socioeconomic, legal and cultural factors that contribute to suicide should be considered.

Moral Injury and Suicide Ideation Among Combat Veterans

Background: Modern warfare in a civilian setting may expose combatants to severe moral challenges. Whereas most of these challenges are handled effectively, some potentially morally injurious events (PMIEs) may have deleterious psychological effects on the combatants, such as suicide ideation (SI). Self-disclosure, which includes sharing distressing thoughts and emotions, has been recognized as a protective factor against SI in the aftermath of stressful events. The current study is the first to examine the moderating role of self-disclosure in the relationship between PMIE exposure and SI among combat veterans. Method: A sample of 190 recently discharged Israeli combat veterans completed validated self-report questionnaires measuring combat exposure, PMIEs, depressive symptoms, SI, and self-disclosure in a cross-sectional design study. Results: PMIE dimensions and self-disclosure significantly contributed to current SI. Notably, the moderating model indicated that self-disclosure moderated the link between PMIE-Self and current SI, as PMIE-Self and current SI demonstrated a stronger association among veterans with low self-disclosure than among those with high self-disclosure. Limitations: Cross-sectional design of volunteers, the findings may not be directly generalizable to veterans' population. Conclusion: Self-disclosure, as a factor promoting a sense of belongingness, interpersonal bonding, and support, might diminish SI risk following PMIE exposure. Various mechanisms accounting for these associations are suggested, and the clinical implications of these interactions are discussed.

Revisiting evidence of primary prevention of suicide among adult populations: A systematic overview

BACKGROUNDS

Primary prevention of suicidal behaviors in the general population is required to interrupt the trend of self-inflicted deaths worldwide. We reviewed the evidence of the efficacy of primary prevention of suicide among the adult population.

METHODS

This is an overview of systematic reviews. We searched PubMed, EMBASE, Scopus, PsycINFO, and Cochrane databases to identify articles on suicide prevention strategies in non-clinical populations. For the purpose of overview, only systematic reviews were eligible. Primary outcomes: The outcomes of the present study were changes in the number of suicide death or suicide behaviors. Two reviewers assessed the methodological quality and the risk of bias of included studies.

RESULTS

From the initial 2,315 records, 32 articles met inclusion criteria. Evidence of reduction of suicide-related outcomes was detected, but of small magnitude. Most multicomponent prevention programs were delivered to specific populations, comprising strategies such as restriction to lethal means, educational programs, and gatekeeper training. Means restriction was the single intervention that showed some evidence of individual efficacy in reducing suicide. There is evidence that poor quality of media reporting is related with increasing suicide and better-quality reports could help suicide prevention. Most of the included SRs were of critically-low methodological quality.

LIMITATIONS

Publication bias, reporting bias, study designs, outcome definition and article overlap across studies are the main concerns.

CONCLUSIONS

Multicomponent programs and means restriction have indicated a reduction of suicide rates, mainly in specific populations. There is insufficient evidence to recommend a widespread implementation of suicide primary prevention in the general population.

Anhedonia and Suicide

Suicide is a leading cause of death, and presently, there is no definitive clinical indicator of future suicide behaviors. Anhedonia, a transdiagnostic symptom reflecting diminished ability to experience pleasure, has recently emerged as a risk factor for suicidal thoughts and behaviors (STBs). This overview, therefore, has the following aims. First, prior research relating anhedonia to STBs will be reviewed, with a particular focus on clarifying whether anhedonia is more closely associated with suicidal thoughts versus behaviors. Second, the National Institute of Mental Health's Research Domain Criteria Positive Valence Systems provide a useful heuristic to probe anhedonia across different units of analysis, including clinical symptoms, behaviors, neural mechanisms, and molecular targets. Accordingly, anhedonia-related constructs linked to STBs will be detailed as well as promising next steps for future research. Third, although anhedonia is not directly addressed in leading suicide theories, this review will provide potential inroads to explore anhedonia within diathesis-stress and interpersonal suicide frameworks. Last, novel approaches to treat anhedonia as a means of reducing STBs will be examined.

A virtual, pilot randomized trial of a brief intervention to prevent suicide in an integrated healthcare setting

OBJECTIVE

Patients who die by suicide are often seen in primary care settings in the weeks leading to their death. There has been little study of brief interventions to prevent suicide in these settings.

METHOD

We conducted a virtual, pilot, randomized controlled trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC) in patients who presented to a primary care mental health walk-in clinic for a new mental health intake appointment and were at risk for suicide. Our primary aim was to assess feasibility. We measured our ability to recruit 20 patients. We measured the proportion of enrolled patients who completed all study assessments. We assessed adherence among patients assigned to VA BIC.

RESULTS

Twenty patients were enrolled and 95% (N = 19) completed all study assessments. Among the 10 patients assigned to VA BIC, 90% (N = 9) of patients completed all required intervention visits, and 100% (N = 10) completed ≥70% of the required interventions visits.

CONCLUSION

It is feasible to conduct a virtual trial of VA BIC in an integrated care setting. Future research should clarify the role of VA BIC as a suicide prevention strategy in integrated care settings using an adequately powered design.

CLINICAL TRIAL REGISTRATION

NCT04054947.

Suicidal ideation and behavior in youth in low- and middle-income countries: A brief review of risk factors and implications for prevention

Although global rates of suicide have dropped in the last 30 years, youth in low- and middle-income countries (LMICs) continue to be highly represented in suicide statistics yet underrepresented in research. In this review we present the epidemiology of suicide, suicidal ideation, and suicide attempts among youth in LMICs. We also describe population-level (attitudes toward suicide, socioeconomic, and societal factors) and individual-level clinical and psychosocial risk factors, highlighting specific considerations pertaining to youth in LMICs. These specific considerations in risk factors within this population can inform how multi-level prevention strategies may be targeted to meet their specific needs. Prevention and intervention strategies relying on the stepped-care framework focusing on population-, community-, and individual level targets while considering locally- and culturally relevant practices are key in LMICs. In addition, systemic approaches favoring school-based and family-based interventions are important among youth. Cross-culturally adapted multimodal prevention strategies targeting the heterogeneity that exists in healthcare systems, suicide rates, and risk factors in these countries should be accorded a high priority to reduce the burden of suicide among youth in LMICs.

[Suicides in the German prison system: frequency, risk factors, and prevention]

Gefangene haben ein hohes Suizidrisiko und die höchsten Suizidraten sind bei Untersuchungsgefangenen zu verzeichnen. Suizid ist die häufigste singuläre Todesursache in deutschen Gefängnissen. In diesem narrativen Übersichtsbeitrag werden zunächst die Gefängnispopulation und ihre allgemeine Gesundheitsversorgung beschrieben, wobei insbesondere auf psychiatrische und Substanzkonsumstörungen eingegangen wird. Der Hauptteil widmet sich der Prävalenz, den Ursachen und Risikofaktoren von Gefängnissuizid. Maßnahmen zur Suizidprävention werden dargestellt.

Der Anteil von Männern unter Gefangenen in Deutschland ist mit 94 % (2020) wie in allen Teilen der Welt sehr hoch. Die meisten Gefangenen sind jungen oder mittleren Alters. Die durchschnittlichen jährlichen Suizidraten bei Männern und Frauen in deutschen Gefängnissen entsprechen mit 105,8/100.000 bzw. 54,7/100.000 denen der meisten Länder in der Europäischen Union (Vollerhebung 2000–2011). Die Suizidraten bei männlichen deutschen Gefangenen sind in den Jahren 2000–2013 unabhängig vom Alter kontinuierlich zurückgegangen. Bei weiblichen Gefangenen stiegen sie dagegen an, wobei die Ursachen hierfür nicht bekannt sind. Es gibt Hinweise darauf, dass psychiatrische Erkrankungen nicht erkannt worden waren.

Wichtige suizidpräventive Maßnahmen sind die Unterbringung in Gemeinschaft und die Vermeidung von Isolation, beispielsweise durch das Angebot von Arbeit. Zudem stehen validierte deutschsprachige Screeninginstrumente zur Verfügung, um ein Suizidrisiko frühzeitig zu erkennen. Für eine wirksame Gefängnissuizidprävention bedarf es der Identifikation von Hochrisikopersonen, des Angebots geeigneter suizidpräventiver Maßnahmen sowie der Entwicklung teambezogener Maßnahmen beim Gefängnispersonal.

Comparing the predictive value of screening to the use of electronic health record data for detecting future suicidal thoughts and behavior in an urban pediatric emergency department: A preliminary analysis

AIM

Brief screening and predictive modeling have garnered attention for utility at identifying individuals at risk of suicide. Although previous research has investigated these methods, little is known about how these methods compare against each other or work in combination in the pediatric population.

METHODS

Patients were aged 8-18 years old who presented from January 1, 2017, to June 30, 2019, to a Pediatric Emergency Department (PED). All patients were screened with the Ask Suicide Questionnaire (ASQ) as part of a universal screening approach. For all models, we used 5-fold cross-validation. We compared four models: Model 1 only included the ASQ; Model 2 included the ASQ and EHR data gathered at the time of ED visit (EHR data); Model 3 only included EHR data; and Model 4 included EHR data and a single item from the ASQ that asked about a lifetime history of suicide attempt. The main outcome was subsequent PED visit with suicide-related presenting problem within a 3-month follow-up period.

RESULTS

Of the N = 13,420 individuals, n = 141 had a subsequent suicide-related PED visit. Approximately 63% identified as Black. Results showed that a model based only on EHR data (Model 3) had an area under the curve (AUC) of 0.775 compared to the ASQ alone (Model 1), which had an AUC of 0.754. Combining screening and EHR data (Model 4) resulted in a 17.4% (absolute difference = 3.6%) improvement in sensitivity and 13.4% increase in AUC (absolute difference = 6.6%) compared to screening alone (Model 1).

CONCLUSION

Our findings show that predictive modeling based on EHR data is helpful either in the absence or as an addition to brief suicide screening. This is the first study to compare brief suicide screening to EHR-based predictive modeling and adds to our understanding of how best to identify youth at risk of suicidal thoughts and behaviors in clinical care settings.

Therapeutic Risk Management and Firearm-related Lethal Means Safety

Safety planning to reduce suicide or other-directed violence risk involves efforts toward "making the environment safe," including working collaboratively with at-risk patients to encourage voluntary changes in their firearm storage decisions [ie, lethal means safety (LMS) counseling]. This column provides a conceptual framework and real-world evidence to support the delivery of LMS counseling to at-risk patients, as well as guidance on asking about firearm access and making individualized safety recommendations. It also reviews important elements related to documenting LMS discussions and legal considerations related to these conversations.

Attempted suicide rates before and during the COVID-19 pandemic: interrupted time series analysis of a nationally representative sample

BACKGROUND

To characterize the association between the protracted biopsychosocial coronavirus disease 2019 (COVID-19) pandemic exposures and incident suicide attempt rates.

METHODS

Data were from a nationally representative cohort based on electronic health records from January 2013 to February 2021 (N = 852 233), with an interrupted time series study design. For the primary analysis, the effect of COVID-19 pandemic on incident suicide attempts warranting in-patient hospital treatment was quantified by fitting a Poisson regression and modeling the relative risk (RR) and the corresponding 95% confidence intervals (CIs). Scenarios were forecast to predict attempted suicide rates at 10 months after social mitigation strategies. Fourteen sensitivity analyses were performed to test the robustness of the results.

RESULTS

Despite the increasing trend in the unexposed interval, the interval exposed to the COVID-19 pandemic was statistically significant (p < 0.001) associated with a reduced RR of incident attempted suicide (RR = 0.63, 95% CI 0.52-0.78). Consistent with the primary analysis, sensitivity analysis of sociodemographic groups and methodological factors were statistically significant (p < 0.05). No effect modification was identified for COVID-19 lockdown intervals or COVID-19 illness status. All three forecast scenarios at 10 months projected a suicide attempt rate increase from 12.49 (7.42-21.01) to 21.38 (12.71-35.99).

CONCLUSIONS

The interval exposed to the protracted mass social trauma of the COVID-19 pandemic was associated with a lower suicide attempt rate compared to the unexposed interval. However, this trend is likely to reverse 10 months after lifting social mitigation policies, underscoring the need for enhanced implementation of public health policy for suicide prevention.

Suicide reduction in Canada during the COVID-19 pandemic: lessons informing national prevention strategies for suicide reduction

Objective

The objective of this research was to evaluate the impact of federal, public health and social support programs on national suicide rates in Canada.

Design

Cross-sectional study.

Setting

Canadian National Database (i.e., Statistics Canada) and Statista.

Participants

Population-level data, and economic and consumer market data.

Main Outcome Measures

Suicide mortality data, population data and unemployment data were obtained from available statistical databases (e.g. Statistics Canada). We quantified suicide rate by dividing the total number of suicide deaths by the national population expressed as a rate per 100,000 population.

Results

Overall suicide mortality rate decreased in Canada from 10.82 deaths per 100,000 in the March 2019 - February 2020 period to 7.34 per 100,000 (i.e. absolute difference of 1300 deaths) in the March 2020 - February 2021 period. The overall Canadian unemployment rate changed from an average monthly rate of 5.7% in 2019 to 9.5% in 2020.

Conclusion

Our results indicate that for the first post-pandemic interval evaluated (i.e., March 2020 - February 2021), suicide rates in Canada decreased against a background of extraordinary public health measures intended to mitigate community spread of COVID-19. An externality of public health measures was a significant rise in national unemployment rates in population measures of distress. Our results suggest that government interventions that broadly aim to reduce measures of insecurity (i.e., economic, housing, health), and timely psychiatric services, should be prioritised as part of a national suicide reduction strategy, not only during but after termination of the COVID-19 pandemic.

Characteristics and Circumstances Associated with Work-Related Suicides from the National Violent Death Reporting System, 2013-2017

Workplaces are critical in suicide prevention because work-related factors can be associated with suicide, and because workplaces can be effective suicide prevention sites. Understanding the circumstances associated with work-related suicides can advance worksite prevention efforts. Data from the United States Centers for Disease Control and Prevention, National Violent Death Reporting System from 2013 to 2017 were used to examine characteristics and circumstances associated with work compared with non-work suicides. Work-related suicides included those indicated as work-related on the death certificate or in which the death investigation mentioned a work problem or work crisis. Of the 84,389 suicides, 12.1% had some relation to the decedent’s work. Males, those aged 21–54, and with at least a college education, were most likely to have work-related suicides. The circumstances most strongly associated with work-related suicide were financial problems (Odds Ratio (OR) = 4.7; 95% Confidence Interval (CI) = 4.5–5.0), prior depressed mood (OR = 2.4; 95% CI = 2.3–2.5), and eviction/loss of home (OR = 1.6; 95% CI = 1.4–1.7). Suicides among healthcare practitioners and management occupations had the highest odds of being work-related. Workplace wellness programs can consider incorporating services, such as financial planning and mental health services, as potentially up-stream approaches to prevent work-related suicide.

Suicide Prevention Mobile Apps for Indian Users: An Overview

Suicide is an issue of global concern. Mobile applications (apps), if found effective, could supplement suicide prevention efforts by addressing some of the barriers to help-seeking. This study aimed to review the nature of suicide prevention apps available for Indian users using the Android platform. Apps identified were broadly reviewed on general features, inclusion of educative elements, suicide risk assessment, and strategies to manage suicidal thoughts. The search terms “suicide,” “suicide prevention,” and “feeling suicidal” were used to search the Google Play Store from May to December 2020, and apps exclusively focusing on suicide prevention were identified and reviewed.

The initial search resulted in 492 apps, of which 43 met inclusion criteria and were further assessed. Fewer than half the apps included supplementary information to users on scientific, evidence-based content (32.55%), and only a few apps were reported to be empirically validated (11.62%). Approximately one-third of the apps intended for people at suicidal risk had an initial screening aspect (16.12%), and one-third of the apps intended for support providers had a suicide risk assessment tool (25.92%). Most apps (81.39%) included a suicide helpline number specific to the region where they were developed, but only a few (23.25%) included motivational elements to call helplines. Common therapeutic strategies suggested to manage suicidal thoughts included distraction, means restriction, environment safety, perspective-shifting strategies, and calming or soothing strategies. Several apps (39.53%) included therapeutic strategies through safety plans.

For apps to be used effectively for suicide prevention, they should include evidence-based content and motivational elements to call helplines, and and clinicians need to examine app features and content before recommending them for use by patients.

Suicide prevention and COVID-19

INTRODUCTION

Suicide prevention during Covid 19 has become a global priority because the current pandemic has led to societal difficulties threatening the fabric of our lifestyle with increased morbidity and mortality. Modelling studies published since the COVID 19 pandemic was declared in March 2020 estimate that suicide rates will increase by anywhere between 1% to 145% globally in response to the pandemic and action needs to be taken.

METHODS

A narrative literature review on high quality evidence sources limited to human studies and publications written in English language only has been used to examine the relationship of COVID 19 and existing mental illness or history of mental illness, suicide prevention strategies and changes in overall suicide rates.

RESULTS

A total of 39 papers are summarised and grouped using the headings aetiological factors, proposed interventions to increase access and national policies to provide a framework for suicide prevention during pandemics such as COVID 19. This review indicates that 1) investing in active labour market programmes will result in a decreased suicide rate during times of high unemployment 2) People in low paid and casual jobs require specific support because they are most financially vulnerable during a pandemic related crisis 3) Women require specific support during a pandemic because of the type of employment they have and because they often carry a greater proportion of the domestic burden and are at increased risk of domestic violence during lockdown and crisis 4) Mental health and substance misuse services need to be appropriately funded and prioritised during and post pandemic, due to the associated increase in substance misuse during a pandemic causing worsening mental health and increased risk of suicide 5) National Suicide Prevention Strategies should be developed by all countries and should anticipate response to a range of disasters, including a pandemic 6) Suicide prevention is everybody's business and National Suicide Prevention Strategies should adopt a whole-systems approach including mental health services, primary care, social care, NGO's and other community stakeholders 7) Suicide is preventable 8) It is essential to prioritise suicide prevention strategies in the COVID and post-COVID period to ensure that lives are saved.

DISCUSSION

Increase in suicide is not inevitable and suicide prevention during pandemics and post COVID 19 pandemics requires a collaborative whole system approach. We require real time data to inform dynamic action planning.

Understanding Vulnerability to Late-Life Suicide

PURPOSE OF REVIEW

We review recent evidence on suicide among older adults, examine risk factors contributing to vulnerability to late-life suicide, and summarize possible interventions.

RECENT FINDINGS

We found a steadily increasing rate of late-life suicide in the USA in the past decade. Evidence supporting the integration of depression care managers into primary care for risk reduction is among the strongest to date. Pharmacologic and neuromodulation studies should be considered in geriatric depression complicated by suicidality. Broad societal campaigns about suicide education, as well as active outreach to psychiatric patients after discharge or a suicidal crisis, prevent suicidal behavior. Growing research supports an integrative multidisciplinary approach. Suicide is a complex and multifaceted behavior with numerous casual points for intervention. Access to deadly means, presence of depression, disease, disability, and social disconnection are factors that increase vulnerability. Quality geriatric care, regular screening in primary and emergency care settings, and a multidisciplinary approach are necessary to mitigate risk factors. The COVID-19 pandemic amplifies need for a more aggressive approach.

Temporal Trends in Suicidal Ideation and Attempts Among US Adolescents by Sex and Race/Ethnicity, 1991-2019

Importance

Disparities by sex and racial/ethnic group in suicide death rates are present in US adolescents. Whether disparities in suicide death extend to groups targeted for suicide prevention efforts, namely, those with suicidal ideation or nonfatal suicide attempts, is unknown.

Objective

To examine differences in temporal trends between suicidal ideation and suicide attempts in US adolescents from 1991 through 2019 by sex and race/ethnicity subgroups.

Design, Setting, and Participants

A cross-sectional analysis of the national Youth Risk Behavior Survey, weighted to represent US adolescents from 1991 to 2019, included 183 563 US high-school students in grades 9 to 12. Data were analyzed from September 16, 2020, through April 12, 2021.

Exposures

Calendar year, sex, race/ethnicity, and interactions of sex and race/ethnicity.

Main Outcomes and Measures

Survey-weighted prevalence estimates, annual percentage changes (APCs) and average APC in the survey-weighted prevalence of suicidal ideation and nonfatal suicide attempts, constructed from self-reported suicidal ideation, plan, and attempts in each survey year, by sex, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian or Pacific Islander and Native Hawaiian, American Indian/Alaska Native), and their interactions (sex × race/ethnicity).

Results

In 183 563 (unweighted) included adolescents (mean [SD] age, 16.07 [1.23] years; 94 282 females [weighted percentage, 49.4%; 95% CI, 48.8%-50.1%]), the prevalence of suicidal ideation decreased from 1991 to 2019 (from 19.4% to 15.8%; 95% CI, 0.7%-0.9%), whereas the prevalence of nonfatal suicide attempts increased from 1991 to 2019 (from 7.3% to 8.9%; 95% CI, 1.0%-1.4%). Joinpoint regression indicated a -3.1% (95% CI, -3.7% to -2.6%) annual decrease in suicidal ideation between 1991 and 2009, followed by a 3.4% annual increase (95% CI, 1.9% -4.8%) between 2009 and 2019. Decreasing followed by increasing trends in suicidal ideation showed modestly different turning points in female (1991-2009, 2009-2019), White (1991-2009, 2009-2019), Hispanic (1991-2007, 2007-2019), and Black (1991-2005, 2005-2019) adolescents. Although no significant trends were observed in suicide attempts from 1991 through 2019, male (68.4% increase; 95% CI, 0.2% -1.2%) and Black (79.7% increase; 95% CI, 0.1%-1.5%) adolescents had greater increases in the prevalence of suicide attempts. Interaction of sex and race/ethnicity revealed increases in suicidal ideation in White females from 2009 to 2019 (APC, 4.3%; 95% CI, 1.5%-7.1%), Black females from 2005 to 2019 (APC, 3.4%; 95% CI, 1.4%-5.4%), and Hispanic females from 2009 to 2019 (APC, 3.3%; 95% CI, 1.0%-5.6%) and suicide attempts in White females from 2009 to 2019 (APC, 3.1%; 95% CI, 0.3%-6.0%).

Conclusions and Relevance

The findings of this study show apparent sex and racial/ethnic differences in trends in suicidal ideation and suicide attempts. Increases in suicidal ideation since 2009 were observed in female individuals; changes in male and Black adolescents represented the largest increase in the prevalence of suicide attempts between 1991 and 2019. Evidence-based suicide prevention programs need to be tailored by sex and race/ethnicity, calling for greater diversification of health care system, school, and community prevention approaches.