Crucial elements in suicide prevention strategies

An Open Trial of a Brief, Self-Compassion Intervention Targeting Thwarted Belongingness and Perceived Burdensomeness

OBJECTIVE

Suicide is a global health concern and developing brief and accessible interventions that can reduce suicide risk is crucial. Thwarted belongingness (TB; i.e., feeling like one doesn't belong) and perceived burdensomeness (PB; i.e., feeling like one is a burden on others) are associated with suicidality, and changes in these constructs predict changes in suicidal thoughts and behaviors. Self-compassion is a multifaceted construct that involves being open and kind to oneself and can be taught through brief writing tasks. Low self-compassion has been associated with TB, PB, and suicidal ideation, suggesting that enhancing self-compassion may decrease suicide risk. Thus, we conducted an open trial of a brief, online self-compassion intervention targeting TB and PB.

METHOD

Undergraduate students (N = 132) viewed an educational video on self-compassion and completed self-compassion writing tasks over the course of one week.

RESULTS

Reactions to the intervention were positive, and participants reported significantly higher self-compassion scores following the intervention. However, TB and PB scores did not change from the baseline to the post-intervention assessment.

CONCLUSIONS

This open trial demonstrated the feasibility and acceptability of a fully online, brief self-compassion intervention, but its impact on reducing suicide risk should be assessed further using a randomized controlled design.

Suicide risk, related factors and the impact of COVID-19 amongst suicide prevention helpline callers: A network analysis

BACKGROUND

The COVID-19 pandemic brought along many known risk factors for suicide. It is important to map out contributing and protective factors for suicide risk and examine possible changes in these associations during pandemics such as COVID-19. The current study aimed to examine how information on risk and protective factors obtained through a suicide prevention helpline is linked to the assessed suicide risk and the possible impact of the COVID-19 pandemic.

METHODS

Data on 9474 calls registered by operators of the suicide prevention helpline of Flanders (i.e., part of Belgium) were analysed using network analysis. Using network analyses allowed for a data-driven examination of direct and indirect pathways through which risk and protective factors are associated to perceived suicide risk. The network before and during COVID-19 were compared to examine the possible impact of the pandemic.

RESULTS

Our findings suggest that different vulnerability and protective factors contribute to perceived suicide risk. Experiencing a break-up, abuse, previous attempt(s), experienced difficulties with the healthcare system and availability of resources were directly and uniquely associated with perceived suicide risk before and during COVID-19.

LIMITATIONS

Main limitations of this study are the possible bias of operator assessment accuracy, absence of several important psychological risk factors and the use of cross-sectional data.

CONCLUSIONS

The current study provides insight in the effect of COVID-19 on suicidality and its risk and protective factors amongst suicide prevention helpline users, a population with high risk of suicide. Implications for suicide prevention helplines are discussed.

Psychiatric profiles in suicidal attempters: Relationships with suicide behaviour features

BACKGROUND

Suicide constitutes a major health concern worldwide, being a significant contributor of death, globally. The diagnosis of a mental disorder has been extensively linked to the varying forms of suicidal ideation and behaviour. The aim of our study was to identify the varying diagnostic profiles in a sample of suicide attempters.

METHODS

A sample of 683 adults (71.3% females, 40.10±15.74 years) admitted at a hospital emergency department due to a suicide attempt was recruited. Latent class analysis was used to identify diagnostic profiles and logistic regression to study the relationship between comorbidity profile membership and sociodemographic and clinical variables.

RESULTS

Two comorbidity profiles were identified (Class I: low comorbidity class, 71.3% of attempters; Class II: high comorbidity class, 28.7% of attempters). Class I members were featured by the diagnosis of depression and general anxiety disorder, and low comorbidity; by contrast, the high comorbidity profile was characterized by a higher probability of presenting two or more coexisting psychiatric disorders. Class II included more females, younger, with more depressive symptoms and with higher impulsivity levels. Moreover, Class II members showed more severe suicidal ideation, higher number of suicide behaviours and a greater number of previous suicide attempts (p<.01, for all the outcomes), compared to Class I members.

CONCLUSIONS

Psychiatric profiles may be considered for treatment provision and personalized psychiatric treatment in suicidal attempters as well as tackle suicide risk.

Addressing help-seeking, stigma and risk factors for suicidality in secondary schools: short-term and mid-term effects of the HEYLiFE suicide prevention program in a randomized controlled trial

BACKGROUND

Suicidal ideation and suicide attempts present a serious public health concern among adolescents and young adults. School-based suicide prevention programs are a key tool for addressing this problem. However, more research is necessary to assess their effectiveness, acceptability, and safety. In response, the HEYLiFE suicide prevention program was developed to enhance help-seeking, reduce stigma towards suicidal peers and diminish risk factors for suicidality. This article presents the evaluation findings of the HEYLiFE program in German secondary schools.

METHODS

We conducted a randomized-controlled trial measuring short-term pre-post within-group effects in the intervention group only and mid-term effects at 6-months-follow-up compared to a waitlist-control group. Schools were assigned randomly to the intervention or control group (no blinding). We recruited students ≥12 years of age. Primary outcomes were knowledge about suicidality, attitudes towards suicidality, stigma towards a suicidal peer, help-seeking intentions and behaviours, risk factors for suicidality. The data was analysed with linear mixed models and generalized linear mixed models.

RESULTS

A total of N = 745 students participated (n = 353 intervention group, n = 392 control group). We observed favourable short-term effects on knowledge, attitudes towards suicidality and fear towards a suicidal peer. Unexpectedly, the program also led to an increase in desire for social distance and a decrease in prosocial emotions towards a suicidal peer. The mid-term effects of the program were exclusively favourable, resulting in enhanced attitudes towards help-seeking while protecting from a sharper rise in risk-factors for suicidality and from an increase in social distance. The program had more favourable effects on females and on students aged >13 years. The program was well-received by the students, and no serious adverse events were reported.

CONCLUSIONS

These findings demonstrate the effectiveness of the HEYLiFE universal suicide prevention program in addressing variables associated with suicidal ideation and suicide attempts among adolescents on the mid-term. The short-term negative effects on stigma and more negative effects on males should be addressed in the future. Future evaluation studies should examine its effects on suicidality and its effectiveness within populations at high risk.

TRIAL REGISTRATION

The study was preregistered in the German Clinical Trials Register (registration number: DRKS00017045; registration date: 02/04/2019).

Suicide trends in Denmark-An ecological study exploring suicide methods from 1995 to 2019

Suicide is a major public health problem and complex phenomenon, affecting many people around the world. However, the incidence of suicide varies by sex and age, which includes differences in the means used. Therefore, to implement effective preventative interventions, it is important to study these differences to design effective, preventative interventions. This study investigates the trends in suicide rates in Denmark from 1995 to 2019 by analysing changes based on sex, age, and the means used for suicide. Data on all suicide deaths in the study period were extracted from the Danish Register of Causes of Death, and data on the background population were obtained from Statistics Denmark. We used negative binomial regression models to analyse the data, and the obtained estimates as a logarithm of the rate ratios allowed us to compare the results across groups and years. An overall decline in Danish suicide rates was observed during the study period, with the exception of young females aged 15-29 years. The demographic composition did not change significantly, and suicide rates are still highest for males and the elderly aged 60+. Hanging, self-poisoning and firearms remain the most prevalent means of suicide. Suicide prevention initiatives are required, especially interventions targeting males and the elderly. Restricting access to the means of suicide for these groups with high fatality rates may help reduce the overall suicide rate. Moreover, more research is needed to understand the factors that lead to suicide and affect the choice of means, which should also include studying the effects of different suicide prevention strategies on males and females from different age groups.

Risk of suicide attempt repetition after an index attempt: A systematic review and meta-analysis

OBJECTIVES

To estimate the risk of suicide attempt repetition among individuals with an index attempt. It also aims to study the role of risk factors and prevention programme in repetition.

METHODS

This systematic review and meta-analysis was conducted in keeping with the PRISMA 2020 guidelines. Studies on attempt repetition (both cohort studies and intervention studies) were searched from inception to 2022.

RESULTS

A total of 110 studies comprising 248,829 attempters was reviewed. The overall repetition rate was 0.20 (0.17, 0.22). Repetition risk linearly increased over time. A higher risk of attempt repetition was associated with female sex and index attempts in which self-cutting methods were used. Moreover, a mental disorder diagnosis was associated with an increasing repetition risk (OR = 2.02, p < .01). The delivery of a preventive programme reduced the repetition risk, OR = 0.76, p < .05; however, this effect was significant for psychotherapy interventions, OR = 0.38, p < .01.

CONCLUSION

One in five suicide attempters will engage in a new suicide attempt. An elevated repetition risk is associated with being female, more severe index methods and psychiatric disorder diagnosis. Preventive programmes, particularly psychotherapy, may contribute to reducing repetition risk and eventually save lives.

Systematic review and narrative synthesis of suicide prevention in high-schools and universities: a research agenda for evidence-based practice

Background

Youth suicide prevention in high-schools and universities is a public health priority. Our aim was to propose a research agenda to advance evidence-based suicide prevention in high-schools and universities by synthesizing and critically reviewing the research focus and methodologies used in existing intervention studies.

Methods

Fourteen databases were systematically searched to identify studies which evaluate suicide prevention interventions delivered on high-school or university campuses, with before and after measures. Data from included studies (n = 43) were extracted to identify what, where, how and for whom interventions have been tested. Narrative synthesis was used to critically evaluate research focus and methodology. Study quality was assessed.

Results

Research has focused primarily on selective interventions, with less attention on indicated and universal interventions. Most evidence comes from North America and high-income countries. The target of interventions has been: non-fatal suicidal behaviour; confidence and ability of staff/students to intervene in a suicidal crisis; suicide-related knowledge and attitudes; and suicide-related stigma. No studies included suicide deaths as an outcome, evaluated eco-systemic interventions, explored how context influences implementation, used multisite study designs, or focused explicitly on LGBTQ+ youth. Two studies evaluated digital interventions. Quality of the majority of studies was compromised by lack of methodological rigour, small samples, and moderate/high risk of bias. Interventions often assume the existence of an external well-functioning referral pathway, which may not be true in low-resource settings.

Conclusion

To advance evidence-based suicide prevention in educational settings we need to: conduct more high-quality clinical and pragmatic trials; promote research in low- and middle-income countries; test targeted interventions for vulnerable populations (like LGBTQ+ youth), evaluate interventions where death by suicide is the primary outcome; include translational studies and use implementation science to promote intervention uptake; evaluate the potential use of digital and eco-systemic interventions; and conduct multisite studies in diverse cultural settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11124-w.

Dos and Don'ts in Designing School-Based Awareness Programs for Suicide Prevention

Abstract.Background: Despite the promising evidence for the effectiveness of school-based awareness programs in decreasing the rates of suicidal thoughts and suicide attempts in young people, no guidelines on the targets and methods of safe and effective awareness programs exist. Aims: This study intends to distill recommendations for school-based suicide awareness and prevention programs from experts. Method: A three-stage Delphi survey was administered to an expert panel between November 2018 and March 2019. A total of 214 items obtained from open-ended questions and the literature were rated in two rounds. Consensus and stability were used as assessment criteria. Results: The panel consisted of 19 participants in the first and 13 in the third stage. Recommended targets included the reduction of suicide attempts, the enhancement of help-seeking and peer support, as well as the promotion of mental health literacy and life skills. Program evaluation, facilitating access to healthcare, and long-term action plans across multiple levels were among the best strategies for the prevention of adverse effects. Limitations: The study is based on opinions of a rather small number of experts. Conclusion: The promotion of help-seeking and peer support as well as facilitating access to mental health-care utilities appear pivotal for the success of school-based awareness programs.

Health beliefs as a predictor of screening behaviors among college students

Twenty million people live with a sickle cell disease (SCD) diagnosis globally; about 100,000 reside in the United States of America (US). Although SCD continues to threaten the health, mostly of particular groups in the US, there is a lack of knowledge on risk factors such as unawareness of carrier status, inheritance patterns, and resistance to SCT screening among childbearing age individuals. A cross-sectional survey design using a modified version of the Health Belief Survey assessed college students' SCD beliefs and screening behaviors. Four hundred sixteen students from a North Texas university campus participated in the survey. Although most participants believed that knowing their carrier status was important, only 26% were aware of their status. Findings demonstrated that health beliefs were a significant predictor of screening behaviors. The Universal, Selective, and Indicated Prevention Approach was suggested as a suitable approach to educate, transform health beliefs, and augment screening participation.

Universal interventions for suicide prevention in high-income Organisation for Economic Co-operation and Development (OECD) member countries: a systematic review

INTRODUCTION

To examine the effectiveness of universal suicide prevention interventions on reducing suicide mortality in high-income Organisation for Economic Co-operation and Development (OECD) member countries.

METHODS

We implemented a comprehensive search strategy across three electronic databases: MEDLINE (Ovid), PsycINFO (Ovid) and Embase (Ovid). All studies using time-series, retrospective, prospective, pre-post or cross-sectional study designs were included. Studies were required to examine suicide mortality as the outcome of interest. To help organise the results, studies were grouped into six broad categories of universal interventions consistent with the World Health Organization (WHO) Comprehensive Mental Health Action Plan. A narrative synthesis of results was used to describe the findings.

RESULTS

Of the 15 641 studies identified through the search strategy, 100 studies were eligible in the following categories: law and regulation reforms (n=66), physical barriers (n=13), community-based interventions (n=9), communication strategies (n=4), mental health policies and strategies (n=7), and access to healthcare (n=1). Overall, 100% (13/13) of the included physical barrier interventions resulted in a significant reduction in suicide mortality. Although only 70% (46/66) of the law and regulation reform interventions had a significant impact on reducing suicide, they hold promise due to their extended reach. Universal suicide prevention interventions seem to be more effective at reducing suicide among males than females, identifying a need to stratify results by sex in future studies.

CONCLUSIONS

These findings suggest that universal suicide prevention interventions hold promise in effectively reducing suicide mortality in high-income OECD countries.

Resilience as a focus of suicide research and prevention

Suicide is a major medical and social problem. Decades of suicide research have mostly focused on risk factors for suicidal behaviour while overlooking protective factors such as resilience that may help to address this important public health issue. Resilience is the capacity and dynamic process of adaptively overcoming stress and adversity while maintaining normal psychological and physical functioning. Studies conducted over the past 10-15 years suggest that resilience is a protective factor against suicide risk. Resilience is becoming a focus of suicide research and prevention. Building resilience should be a part of universal, selective, and indicated suicide prevention interventions. Promoting resilience may reduce suicide risk in the general population, in groups at elevated suicide risk, and among high-risk individuals. Building resilience in the general population may reduce the incidence of stress-related disorders and, consequently, suicidal behaviour. Improving resilience should be a part of a treatment plan of every psychiatric patient. Mental health professionals will probably have the best success in reducing suicide risk in psychiatric patients if they actively concentrate on increasing stress resilience using both psychosocial and pharmacological interventions. It is critically important to move forward the development of pharmacological and psychological interventions for enhancing resilience.

Knowledge, beliefs, attitudes, and behaviors regarding sickle cell disease: Implications for prevention

Sickle cell disease (SCD) is a widespread inherited blood disorder, which leaves lasting effects on the health, social functioning, and finances of individuals, families, communities, and health care systems. A nonexperimental, cross-sectional research design was used to assess 415 college students' knowledge about SCD. Data was obtained through an online survey derived from a modified version of the SCD Knowledge Assessment Tool. The majority of participants (79%) reported previous SCD knowledge; however, 21% of the participants reported no previous SCD knowledge. Results support the need for improved education and awareness for at risk groups. The lack of SCD knowledge among African Americans shows a need for improved, nongendered specific education, awareness, and screening efforts geared toward at-risk populations.

First and Subsequent Lifetime Alcoholism and Mental Disorders in Suicide Victims With Reference to a Community Sample-the Lundby Study 1947-1997

Background: Suicide victims have been found to frequently suffer from mental disorders, often more than one, and comorbidity has also been found to be a risk factor for suicide. The aim of the present study was to determine the first disorder and possible subsequent disorders in suicide victims during their lifetimes and to compare their development with the development of mental and alcohol use disorders (AUDs) in a community sample. Methods: The Lundby Study is a prospective longitudinal study of mental health in a general population comprising 3,563 subjects, including 68 suicide victims, followed by four field investigations from 1947 to 1997; mortality was monitored up to 2011. Results: AUD was most common as a first diagnosis (26/68, 38.2%) among suicide victims, followed by "depression" (20/68, 29.4%) and "anxiety" (7/68, 10.3%). A predominance of AUD as a first diagnosis was found in the male group, whereas "depression" was the most common first diagnosis in the female group. However, there were very few females with AUD in the Lundby Study. In the whole population, it was more common for someone who started with an AUD to develop a subsequent mental disorder than the other way around. The same was true for AUD in relation to depression. Conclusions: AUD was the most common first mental disorder among male suicide victims and could thus be considered a starting point in the suicidal process. We propose that in addition to detecting and treating depression, it is important to detect and treat AUD vigorously and to be alert for subsequent symptoms of depressive and other mental disorders in suicide prevention efforts.

Longitudinal association between mental disorders in childhood and subsequent depression - A nationwide prospective cohort study

BACKGROUND

Depression ranges among the most impairing mental disorders worldwide, and early detection is a global health priority. Little is known about the association between non-affective mental disorders in childhood/adolescence and later depression.

METHODS

Nationwide register-based prospective cohort study, estimating cumulative incidences and incidence rate ratios (IRR) for later depression in individuals with and without non-affective mental disorders in early life.

RESULTS

475,213 females and 484,813 males born 1990-2007 were followed for a mean of 9.14 years (contributing a total of 8778,331 person-years of observation). In the cohort, 7963 (5451 females) were diagnosed with depression. Depression was more common in individuals with prior non-affective mental disorders in adolescence (15.98% in females and 7.02% in males) and in childhood (4.98% in females and 1.6% in males), than in the background population (3.94% and 1.3% in females; 1.37% and 0.47% in males). Eating and anxiety disorders in childhood/adolescence carried the highest absolute risk of depression. The relative risk of depression was particularly high the first year after the first non-affective disorder (IRR = 15.5; 14.07-17.10), but remained highly elevated more than five years after the first non-affective diagnosis (IRR = 2.05; 1.84-2.28), when compared to young people without such disorders.

LIMITATIONS

This study only included diagnoses given at hospital departments, representing the more severe mental disorders.

CONCLUSIONS

Children and adolescents with non-affective mental disorders were at substantially increased absolute and relative risk of developing depression in young adulthood, especially females diagnosed with anxiety- or eating disorders in adolescence. These findings may help identify groups of children and adolescents at very high risk of developing depression.

The Burden of Suicide in Rural Bangladesh: Magnitude and Risk Factors

The aim of the paper is to quantify the burden and risk factors of fatal and non-fatal suicidal behaviors in rural Bangladesh. A census was carried out in seven sub-districts encompassing 1.16 million people. Face-to-face interviews were conducted at the household level. Descriptive analyses were done to quantify the burden and Poisson regression was run to determine on risk factors. The estimated rates of fatal and non-fatal suicide were 3.29 and 9.86 per 100,000 person years (PY) observed, respectively. The risk of suicide was significantly higher by 6.31 times among 15-17 and 4.04 times among 18-24 olds compared to 25-64 years old. Married adolescents were 22 times more likely to commit suicide compared to never-married people. Compared to Chandpur/Comilla district, the risk of suicide was significantly higher in Narshingdi. Students had significantly lower risk of non-fatal suicidal behavior compared to skilled laborers. The risk of non-fatal suicidal behavior was lower in Sherpur compared to Chandpur/Comilla. Among adolescents, unskilled laborers were 16 times more likely to attempt suicide than students. The common methods for fatal and non-fatal suicidal behaviors were hanging and poisoning. Suicide is a major public health problem in Bangladesh that needs to be addressed with targeted interventions.

Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports

There is a high risk for death by suicide after discharge from an inpatient mental health unit. To better understand system and organizational factors associated with postdischarge suicide, we reviewed root cause analysis reports of suicide within 7 days of discharge from across all Veterans Health Administration inpatient mental health units between 2002 and 2015. There were 141 reports of suicide within 7 days of discharge, and a large proportion (43.3%, n = 61) followed an unplanned discharge. Root causes fell into three major themes including challenges for clinicians and patients after the established process of care, awareness and communication of suicide risk, and flaws in the established process of care. Flaws in the design and execution of processes of care as well as deficits in communication may contribute to postdischarge suicide. Inpatient teams should be aware of the potentially heightened risk for suicide among patients with unplanned discharges.

[University and suicidal behavior: institutional response and actions, Bogotá 2004-2014]

OBJECTIVE

To analyze the institutional responses and actions towards suicidal behavior of students from five universities in Bogotá, and their relation with the National Mental Health Policy (NMHP), the Comprehensive Primary Health Care Guidelines (APS), and the plans established for approaching this issue, to finally make suggestions based on them.

METHODS

Qualitative, exploratory-descriptive study based on the experiences of 66 university workers, who provided inputs on suicide and its characteristics; this study is also grounded on the institutional response of five universities in Bogotá. Semi-structured interviews were also used.

RESULTS

Participating universities have a heteronomous understanding of the phenomenon of suicide, as well as different attention mechanisms, which are mainly directed to administrative support and the prevention of suicidal behavior contagion.

CONCLUSIONS

The consummate suicides of students have served the universities to reflect upon this problem, which has made more visible the problem of dehumanization in training, and the role of university well-being and health services. The appropriateness of inter-institutional and intersectoral networks, psychoeducation, co-responsibility, and the active participation of young people in the discussion and formulation of welfare-oriented approaches and programs are strong aspects that arise from this reflection.

Fatal injuries in rural and urban areas in northern Finland: a 5-year retrospective study

Background

Finland has the fourth highest injury mortality rate in the European Union. To better understand the causes of the high injury rate, and prevent these fatal injuries, studies are needed. Therefore, we set out to complete an analysis of the epidemiology of fatal trauma, and any contributory role for alcohol, long suspected to promote fatal injuries. As a study area, we chose the four northernmost counties of Finland; their mix of remote rural areas and urban centres allowed us to correlate mortality rates with ‘rurality’.

Methods

The Causes of Death Register was consulted to identify deaths from external causes over a 5‐year time period. Data were retrieved from death certificates, autopsy reports and medical records. The municipalities studied were classified as either rural or urban.

Results

Of 2915 deaths categorized as occurring from external causes during our study period, 1959 were eligible for inclusion in our study. The annual crude mortality rate was 54 per 100,000 inhabitants; this rate was higher in rural vs. urban municipalities (65 vs. 45 per 100,000 inhabitants/year). Additionally, a greater number of pre‐hospital deaths from accidental high‐energy trauma occurred in rural areas (78 vs. 69%). 42% of all pre‐hospital deaths occurred under the influence of alcohol.

Conclusion

The crude mortality rate for fatal injuries was high overall as compared to other studies, and elevated in rural areas, where pre‐hospital deaths were more common. Almost half of pre‐hospital deaths occurred under the influence of alcohol.

Suicide and suicidal behaviour

Suicide is a complex public health problem of global importance. Suicidal behaviour differs between sexes, age groups, geographic regions, and sociopolitical settings, and variably associates with different risk factors, suggesting aetiological heterogeneity. Although there is no effective algorithm to predict suicide in clinical practice, improved recognition and understanding of clinical, psychological, sociological, and biological factors might help the detection of high-risk individuals and assist in treatment selection. Psychotherapeutic, pharmacological, or neuromodulatory treatments of mental disorders can often prevent suicidal behaviour; additionally, regular follow-up of people who attempt suicide by mental health services is key to prevent future suicidal behaviour.

A longitudinal study of suicidal ideation among homeless, mentally ill individuals

PURPOSE

Previous cross-sectional studies have indicated that homeless individuals may present with high rates of suicidal ideation, which are strongly associated with completed suicide. We conducted the first known longitudinal study of suicidal ideation in the homeless.

METHODS

We used data collected over 24 months in the Vancouver At Home project (N = 497), comprised two randomized-controlled trials of housing interventions for homeless individuals with mental disorders. Presence of suicidal ideation was determined using the Colorado symptom index.

RESULTS

Suicidal ideation significantly decreased over time [odds ratio (OR) = 0.31 at 24 months, 95 % confidence interval (CI) 0.21-0.46]. Baseline diagnoses of mood (OR = 2.18, 95 % CI 1.48-3.21) and anxiety disorders (OR = 2.05, 95 % CI 1.42-2.97), as well as depressive mood (OR = 2.52, 95 % CI 1.90-3.33), use of any substance (OR = 1.59, 95 % CI 1.09-2.32), and polysubstance use (OR = 1.90, 95 % CI 1.40-2.60) were significantly associated with suicidal ideation in the multivariate model. Baseline diagnosis of a psychotic disorder (protective effect), daily substance use, intravenous drug use, recent arrest, multiple physical illnesses and history of traumatic brain injury were significantly associated with suicidal ideation in the unadjusted model only.

CONCLUSIONS

Interventions targeting depressive symptoms and substance use could help decrease suicide risk in homeless individuals. Mental health services need to be tailored to address the complex needs of socially marginalized individuals.

TRIAL REGISTRATION

Current controlled trials: ISRCTN57595077 (Vancouver At Home study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual) and ISRCTN66721740 (Vancouver At Home study: Housing first plus intensive case management versus treatment as usual). Assigned 9 Oct. 2012.

Alterations in circadian/seasonal rhythms and vegetative functions are related to suicidality in DSM-5 PTSD

BACKGROUND

Alterations in rhythmicity and vegetative functions have been reported as correlates of suicidality, particularly in patients with mood disorders. No investigation has addressed their impact on patients with post-traumatic stress disorder (PTSD). Aim of the present study was to fulfill this gap.

METHODS

Sixty-five out- and inpatients with DSM-5 PTSD were assessed by using the Mood Spectrum-Self Report-Lifetime Version (MOODS-SR), a questionnaire for lifetime mood spectrum symptomatology including alterations in circadian/seasonal rhythms and vegetative functions. Six items of the MOODS-SR were combined and dichotomized to assess suicidal ideation and/or attempts.

RESULTS

Significant and positive associations were found between symptoms of lifetime dysregulations in rhythmicity and vegetative functions and suicidal ideation and/or attempts. All MOODS-SR sub-domains (rhythmicity, sleep, appetite/weight, sexual function, physical symptoms) were associated with an increased likelihood of suicidal ideation, but only changes in appetite/weight were associated with greater odd ratios of suicide attempts (OR = 2.099, 95% CI 1.148-3.841).

CONCLUSIONS

Our results suggest that lifetime dysregulations in rhythmicity and vegetative functions may represent correlates of suicidality in patients with DSM-5 PTSD.

Life span history of non-fatal suicidal behaviours in a large sample of general practitioners' patients: data from Rovigo, Northern Italy

A survey about history of non-fatal suicidal behaviour was performed on 1,171 subjects in the waiting room of general practitioners' practices in the territory of Rovigo (Northern Italy). The mean age of interviewed subjects was 52.9 ± 17.0, with a majority of female individuals. Two and two percent admitted previous experience of non-suicidal self-injury, 4.7 % admitted having had serious suicidal thoughts/plans, and 1.8 % reported at least one suicide attempt. Compared to the rest of the sample, people with history of suicidal behaviours resulted to be of younger age (p < .05), whilst their level of well-being was poorer (p < .001). When compared to the results of the Italian arm of the European Study of the Epidemiology of Mental Disorders, carried out on general population samples, the present study produces higher rates of suicidality, despite the much higher mean age of the interviewed subjects compared to the general population.

Perceived reasons for, opinions about, and suggestions for elders considering suicide: elderly outpatients' perspectives

OBJECTIVES

The purposes of this study were to explore elderly outpatients' perceived reasons for, opinions of, and suggestions for elderly people considering suicide in Taiwan.

METHOD

Elderly outpatients (N = 83) were recruited in 2011-2012 by convenience sampling from three randomly selected medical centers in Taiwan. Data were collected in individual interviews using a semi-structured guide and analyzed by content analysis.

RESULTS

Findings revealed that most participants had heard of elderly suicide, with television news as the main source for their information. Their opinions about elderly suicide reflected judgmental attitudes, negative emotional reactions, expectations of social welfare, and could happen after losing one's meaning in life. Their suggestions for elderly people considering suicide fell into four major themes: give up suicidal ideas, seek help, enhance social welfare, and attend religious activities.

CONCLUSION

Since television news was the main source for participants' information about elderly suicide, this mass medium should be used in suicide prevention to disseminate suicide knowledge, increase access to help, and strengthen suicide-protective factors among the elderly. Furthermore, no participants mentioned depression as a reason for attempted or completed suicide among older people despite depression being a well-known suicide-risk factor. Future suicide-prevention programs should emphasize the role of depression in suicide among older people. Participants also did not suggest that older people considering suicide seek help from the health system. Thus, older people should be educated about the role of the health system in suicide prevention and trained as gatekeepers to recognize signs of suicide ideation and respond appropriately.

Attempted suicide in a Xhosa schizophrenia and schizoaffective disorder population

Suicide risk behavior is a significant contributor to the mortality and morbidity of schizophrenia. We previously reported affected sibship status in a Xhosa schizophrenia or schizoaffective disorder sample to be protective in nature; given the counterintuitive nature of this finding, we expanded the sample size to seek further clarification. Subjects were assessed with the Diagnostic Interview for Genetic Studies and then stratified into two groups: with (n = 137) or without (n = 837) a previous suicide attempt. The presence of lifetime bizarre behavior (OR 1.5; 95% CI 1.12-1.87) or cannabis use or abuse (OR 1.2; 95% CI 10.01-1.47) was a significant predictor of suicide attempts, while a higher global alogia score (OR 0.84; 95% CI 0.74-0.96) was a protective factor. Our data seem to support that in this population, encouraging family members to report bizarre behavior and implementing dual diagnosis interventions for cannabis use or abuse could be an appropriate starting point toward developing a targeted suicide prevention program for further research.

The socio-environmental determinants of railway suicide: a systematic review

BACKGROUND

Railway suicide has significant adverse impacts for the victims, their family and friends, witnesses to the incident, general public and train network. There is no previous review on the socio-environmental factors and railway suicide. The research question asked in this review was: 'What socio-environmental risk and protective predictors are significantly associated with railway suicide?'

METHODS

The review searched Medline, PsycINFO, Web of Science and Scopus for English-language studies that assessed the associations between socio-environmental (i.e. geographical, physical, economic and social) factors and railway suicide from their inception to June 2013. It was reported based on the PRISMA Statement.

RESULTS

Eleven studies met the inclusion criteria. They were categorised into railway environments (availability of railways and trains, accessibility to railways and familiarity with trains), population characteristics and impact of media reporting. Findings from ecological studies using population level railway suicide data suggested weak and inconsistent evidence for the first two categories. The evidence on the impact of media reporting was moderately strong, with irresponsible media reporting being associated with an increased risk of railway suicide.

CONCLUSIONS

There is a need for further research activity to strengthen evidence about socio-environmental risk factors for railway suicide. The focus of this research should be on the factors that determine individuals' decisions of using the railway as a method of suicide, with the consideration of a range of geographical, physical, social, and economic factors.

Forging an agenda for suicide prevention in the United States

Suicide prevention must be transformed by integrating injury prevention and mental health perspectives to develop a mosaic of common risk public health interventions that address the diversity of populations and individuals whose mortality and morbidity contribute to the burdens of suicide and attempted suicide. Emphasizing distal preventive interventions, strategies must focus on people and places--and on related interpersonal factors and social contexts--to alter the life trajectories of people before they become suicidal. Attention also must be paid to those in the middle years--the age with the greatest overall burden. We need scientific and social processes that define priorities and assess their potential for reducing what has been a steadily increasing rate of suicide during the past decade.

Campus suicide prevention: bridging paradigms and forging partnerships

Colleges and universities are increasingly recognizing the need to expand suicide-prevention efforts beyond the standard, clinical-intervention paradigm of suicide prevention, which relies on referral to, and treatment by, mental health services. These services frequently struggle, however, to provide effective, comprehensive care. After reviewing findings that support the need to adopt a broader, problem-focused paradigm, the article provides a framework for bridging this paradigm with the clinical-intervention approach and for conceptualizing a full continuum of preventive interventions. For each level of intervention (ranging from the individual to the ecological), we describe the goals and methods used, and provide examples to illustrate the role of psychiatrists and other campus mental health providers in the collaborative partnerships that must form to support a comprehensive, campus-wide suicide-prevention strategy.

Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after observational study

BACKGROUND

Research investigating which aspects of mental health service provision are most effective in prevention of suicide is scarce. We aimed to examine the uptake of key mental health service recommendations over time and to investigate the association between their implementation and suicide rates.

METHODS

We did a descriptive, cross-sectional, and before-and-after analysis of national suicide data in England and Wales. We collected data for individuals who died by suicide between 1997 and 2006 who were in contact with mental health services in the 12 months before death. Data were obtained as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. When denominator data were missing, we used information from the Mental Health Minimum Data Set. We compared suicide rates for services implementing most of the recommendations with those implementing fewer recommendations and examined rates before and after implementation. We stratified results for level of socioeconomic deprivation and size of service provider.

FINDINGS

The average number of recommendations implemented increased from 0·3 per service in 1998 to 7·2 in 2006. Implementation of recommendations was associated with lower suicide rates in both cross-sectional and before-and-after analyses. The provision of 24 h crisis care was associated with the biggest fall in suicide rates: from 11·44 per 10 000 patient contacts per year (95% CI 11·12-11·77) before to 9·32 (8·99-9·67) after (p<0·0001). Local policies on patients with dual diagnosis (10·55; 10·23-10·89 before vs 9·61; 9·18-10·05 after, p=0·0007) and multidisciplinary review after suicide (11·59; 11·31-11·88 before vs 10·48; 10·13-10·84 after, p<0·0001) were also associated with falling rates. Services that did not implement recommendations had little reduction in suicide. The biggest falls in suicide seemed to be in services with the most deprived catchment areas (incidence rate ratio 0·90; 95% CI 0·88-0·92) and the most patients (0·86; 0·84-0·88).

INTERPRETATION

Our findings suggest that aspects of provision of mental health services can affect suicide rates in clinical populations. Investigation of the relation between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care.

FUNDING

National Patient Safety Agency, UK.

Internet pathways in suicidality: a review of the evidence

The general aim of this study was to review the scientific literature concerning the Internet and suicidality and to examine the different pathways by which suicidal risks and prevention efforts are facilitated through the Internet. An online literature search was conducted using the MEDLINE and Google Scholar databases. The main themes that were investigated included pathological Internet use and suicidality, pro-suicide websites, suicide pacts on the Internet, and suicide prevention via the Internet. Articles were screened based on the titles and abstracts reporting on the themes of interest. Thereafter, articles were selected based on scientific relevance of the study, and included for full text assessment. The results illustrated that specific Internet pathways increased the risk for suicidal behaviours, particularly in adolescents and young people. Several studies found significant correlations between pathological Internet use and suicidal ideation and non-suicidal self-injury. Pro-suicide websites and online suicide pacts were observed as high-risk factors for facilitating suicidal behaviours, particularly among isolated and susceptible individuals. Conversely, the evidence also showed that the Internet could be an effective tool for suicide prevention, especially for socially-isolated and vulnerable individuals, who might otherwise be unreachable. It is this paradox that accentuates the need for further research in this field.