"How" web searches change under stress

To adjust to stressful environments, people seek information. Here, we show that in response to stressful public and private events the high-level features of information people seek online alter, reflecting their motives for seeking knowledge. We first show that when people want information to guide action they selectively ask "How" questions. Next, we reveal that "How" searches submitted to Google increased dramatically during the pandemic (controlling for search volume). Strikingly, the proportion of these searches predicted weekly self-reported stress of ~ 17K individuals. To rule out third factors we manipulate stress and find that "How" searches increase in response to stressful, personal, events. The findings suggest that under stress people ask questions to guide action, and mental state is reflected in features that tap into why people seek information rather than the topics they search for. Tracking such features may provide clues regrading population stress levels.

The Journey of Engaging With Web-Based Self-Harm and Suicide Content: Longitudinal Qualitative Study

BACKGROUND

Self-harm and suicide are major public health concerns worldwide, with attention focused on the web environment as a helpful or harmful influence. Longitudinal research on self-harm and suicide-related internet use is limited, highlighting a paucity of evidence on long-term patterns and effects of engaging with such content.

OBJECTIVE

This study explores the experiences of people engaging with self-harm or suicide content over a 6-month period.

METHODS

This study used qualitative and digital ethnographic methods longitudinally, including one-to-one interviews at 3 time points to explore individual narratives. A trajectory analysis approach involving 4 steps was used to interpret the data.

RESULTS

The findings from 14 participants established the web-based journey of people who engage with self-harm or suicide content. In total, 5 themes were identified: initial interactions with self-harm or suicide content, changes in what self-harm or suicide content people engage with and where, changes in experiences of self-harm or suicide behaviors associated with web-based self-harm or suicide content engagement, the disengagement-reengagement cycle, and future perspectives on web-based self-harm or suicide content engagement. Initial engagements were driven by participants seeking help, often when offline support had been unavailable. Some participants' exposure to self-harm and suicide content led to their own self-harm and suicide behaviors, with varying patterns of change over time. Notably, disengagement from web-based self-harm and suicide spaces served as a protective measure for all participants, but the pull of familiar content resulted in only brief periods of disconnection. Participants also expressed future intentions to continue returning to these self-harm and suicide web-based spaces, acknowledging the nonlinear nature of their own recovery journey and aiming to support others in the community. Within the themes identified in this study, narratives revealed that participants' behavior was shaped by cognitive flexibility and rigidity, metacognitive abilities, and digital expertise. Opportunities for behavior change arose during periods of cognitive flexibility prompted by life events, stressors, and shifts in mental health. Participants sought diverse and potentially harmful content during challenging times but moved toward recovery-oriented engagements in positive circumstances. Metacognitive and digital efficacy skills also played a pivotal role in participants' control of web-based interactions, enabling more effective management of content or platforms or sites that posed potential harms.

CONCLUSIONS

This study demonstrated the complexity of web-based interactions, with beneficial and harmful content intertwined. Participants who demonstrated metacognition and digital efficacy had better control over web-based engagements. Some attributed these skills to study processes, including taking part in reflective diaries, showing the potential of upskilling users. This study also highlighted how participants remained vulnerable by engaging with familiar web-based spaces, emphasizing the responsibility of web-based industry leaders to develop tools that empower users to enhance their web-based safety.

The Language of the Times: Using the COVID-19 Pandemic to Assess the Influence of News Affect on Online Mental Health-Related Search Behavior across the United States

Background

The digital era has ushered in an unprecedented volume of readily accessible information, including news coverage of current events. Research has shown that the sentiment of news articles can evoke emotional responses from readers on a daily basis with specific evidence for increased anxiety and depression in response to coverage of the recent COVID-19 pandemic. Given the primacy and relevance of such information exposure, its daily impact on the mental health of the general population within this modality warrants further nuanced investigation.

Objective

Using the COVID-19 pandemic as a subject-specific example, this work aimed to profile and examine associations between the dynamics of semantic affect in online local news headlines and same-day online mental health term search behavior over time across the United States.

Methods

Using COVID-19–related news headlines from a database of online news stories in conjunction with mental health–related online search data from Google Trends, this paper first explored the statistical and qualitative affective properties of state-specific COVID-19 news coverage across the United States from January 23, 2020, to October 22, 2020. The resultant operationalizations and findings from the joint application of dictionary-based sentiment analysis and the circumplex theory of affect informed the construction of subsequent hypothesis-driven mixed effects models. Daily state-specific counts of mental health search queries were regressed on circumplex-derived features of semantic affect, time, and state (as a random effect) to model the associations between the dynamics of news affect and search behavior throughout the pandemic. Search terms were also grouped into depression symptoms, anxiety symptoms, and nonspecific depression and anxiety symptoms to model the broad impact of news coverage on mental health.

Results

Exploratory efforts revealed patterns in day-to-day news headline affect variation across the first 9 months of the pandemic. In addition, circumplex mapping of the most frequently used words in state-specific headlines uncovered time-agnostic similarities and differences across the United States, including the ubiquitous use of negatively valenced and strongly arousing language. Subsequent mixed effects modeling implicated increased consistency in affective tone (Spin_VA β=–.207; P<.001) as predictive of increased depression-related search term activity, with emotional language patterns indicative of affective uncontrollability (Flux_A β=.221; P<.001) contributing generally to an increase in online mental health search term frequency.

Conclusions

This study demonstrated promise in applying the circumplex model of affect to written content and provided a practical example for how circumplex theory can be integrated with sentiment analysis techniques to interrogate mental health–related associations. The findings from pandemic-specific news headlines highlighted arousal, flux, and spin as potentially significant affect-based foci for further study. Future efforts may also benefit from more expansive sentiment analysis approaches to more broadly test the practical application and theoretical capabilities of the circumplex model of affect on text-based data.

Is Google Trends a useful tool for tracking mental and social distress during a public health emergency? A time-series analysis

BACKGROUND

Google Trends data are increasingly used by researchers as an indicator of population mental health, but few studies have investigated the validity of this approach during a public health emergency.

METHODS

Relative search volumes (RSV) for the topics depression, anxiety, self-harm, suicide, suicidal ideation, loneliness, and abuse were obtained from Google Trends. We used graphical and time-series approaches to compare daily trends in searches for these topics against population measures of these outcomes recorded using validated self-report scales (PHQ-9; GAD-7; UCLA-3) in a weekly survey (n = ~70,000) of the impact COVID-19 on psychological and social experiences in the UK population (21/03/2020 to 21/08/ 2020).

RESULTS

Self-reported levels of depression, anxiety, self-harm/suicidal ideation, self-harm, loneliness and abuse decreased during the period studied. There was no evidence of an association between self-reported anxiety, self-harm, abuse and RSV on Google Trends. Trends in Google topic RSV for depression and suicidal ideation were inversely associated with self-reports of these outcomes (p = 0.03 and p = 0.04, respectively). However, there was statistical and graphical evidence that self-report and Google searches for loneliness (p < 0.001) tracked one another.

LIMITATIONS

No age/sex breakdown of Google Trends data available. Survey respondents were not representative of the UK population and no pre-pandemic data were available.

CONCLUSION

Google Trends data do not appear to be a useful indicator of changing levels of population mental health during a public health emergency, but may have some value as an indicator of loneliness.

First-person accounts of the processes and planning involved in a suicide attempt on the railway

BACKGROUND

The processes and planning involved in choosing and attempting to die by a particular method of suicide are not well understood. Accounts from those who have thought about or attempted suicide using a specific method might allow us to better understand the ways in which people come to think about, plan and enact a suicide attempt.

AIMS

To understand from first-person accounts the processes and planning involved in a suicide attempt on the railway.

METHOD

Thematic analysis was conducted of qualitative interviews (N = 34) undertaken with individuals who had contemplated or attempted suicide by train.

RESULTS

Participants explained how they decided upon a particular method, time and place for a suicide attempt. Plans were described as being contingent on a number of elements (including the likelihood of being seen or interrupted), rather than being fixed in advance. Participants mentally rehearsed and evaluated a particular method, which would sometimes involve imagining in detail what would happen before, during and after an attempt. The extent to which this involved others (train drivers, partners, friends) was striking.

CONCLUSIONS

By giving people free reign to describe in their own words the processes they went through in planning and undertaking a suicide attempt, and by not interpreting such accounts through a lens of deficit and pathology, we can arrive at important insights into how people come to think and feel about, plan and enact a suicide attempt. The findings have implications in terms of understanding suicide risk and prevention more broadly.

Suicide by helium inhalation in the Netherlands between 2012 and 2019

INTRODUCTION

In 2012 and 2013 a movie and a book about a 'dignified end of life' were published in the Netherlands. These items described suicide using an 'exit bag' to establish asphyxiation using helium (the helium method). 'Right-to-die-organisations' inform the elderly about this method. The purpose of this study is to investigate whether the use of suicidal asphyxiation by means of the helium method substituted other, related, methods following its publication in the Netherlands.

MATERIAL AND METHODS

We analysed suicides in the Netherlands over the period from 1 July 2012 to 30 June 2019. We compared the number of deaths caused by the helium method with other, related, cases. Secondly, we related these deaths to the total number of inhabitants and suicides recorded by Statistics Netherlands.

RESULTS

The study showed a stable trend in the use of the helium method in the period 2012-2019 and this was the same for the other, related methods. Individuals using the helium method were significantly younger than those using other, related, methods. At the scene of death, information about suicide and suicide notes were found more often at 'helium method' cases than with the 'other, related, methods' cases. Family was significantly more often present during a helium method suicide than during suicide by other, related, methods.

DISCUSSION

The number of suicides by the helium method and other, related, cases is stable in the Netherlands over the past years. Therefore, we conclude that there is no substitution effect within this category of suicides. Whilst 'right-to-die-organisations' strive to inform the old and sick of the helium method, it is noteworthy that the individuals using the helium method are significantly younger than the individuals who choose other, related, methods.

Searching Online for Methods of Suicide

Background: Information on methods of suicide is available online, and access to information on methods of suicide appears to contribute to a small but significant proportion of suicides. There is limited documentation of how methods of suicide are being profiled, as well as what content exists in other languages than English. Aim: We aimed to analyze and compare how methods of suicide are profiled on Danish and English-language websites. Method: We applied a categorization and content analysis of websites describing methods of suicide. Sites were retrieved by applying widely used Danish and English-language search terms. Results: A total of 136 English-language websites and 106 Danish-language websites were included for analysis. Websites were more often categorized as prevention or support sites, academic or policy sites, and against suicide sites than dedicated suicide sites (i.e., pro-suicide sites), or information sites. However, information on methods of suicide was available, and 20.1% and 8.9% of the English and Danish-language sites, respectively, suggested that a particular method of suicide was quick, easy, painless, or certain to result in death. Limitations: Only one author coded and analyzed all websites. A further operationalization of the content analysis checklist is warranted to increase reliability. Conclusion: The websites primarily had a prevention or anti-suicide focus, but information on methods of suicide was available, requiring an increased focus on how to diminish the negative effects of harmful online content.

Content analysis of suicide-related online portrayals: changes in contents retrieved with search engines in the United States and Austria from 2013 to 2018

BACKGROUND

In recent years, efforts in suicide prevention in the United States and Europe have been made to change the conversation on suicide to incorporate more preventive aspects. The majority of information-seeking occurs online. Structured analyses assessing qualitative changes in retrieved online material on suicide over time, however, are scarce. We replicated a content analysis of suicide-related websites retrieved with popular search engines in the United States and Austria aiming to assess how suicide-related online portrayals have changed in the past five years.

METHOD

We retrieved 396 websites using the search term suicide, method-related search terms (e.g., how to hang yourself), and help-related search terms (e.g., suicide help) in the United States and 286 websites from Austrian searches. We performed a content analysis based on media recommendations for suicide reporting and compared the findings to 335 websites in the United States and 396 websites in Austria retrieved in 2013 with the same procedure.

RESULTS

In both countries, the number of both protective (United States: p < .001, Austria: p < .001) and harmful characteristics (United States: p < .001, Austria: p < .001) increased. The ratio of protective to harmful characteristics improved to 3.3:1 in the United States and to 2.4:1 in Austria.

LIMITATIONS

No assumptions about the actual impact of the retrieved contents can be assumed.

CONCLUSION

There has been an increase in potentially protective aspects in online portrayals of suicidality, but also an increase in potentially harmful characteristics, which may suggest an increasing polarization of suicide-related contents. Future prevention efforts need to address this potential polarization.

Mapping population mental health concerns related to COVID-19 and the consequences of physical distancing: a Google trends analysis

Background: The 2020 Coronavirus pandemic is a major international public health challenge.  Governments have taken public health protection measures to reduce the spread of the virus through non-pharmalogical measures. The impact of the pandemic and the public health response on individual and population mental health is unknown.  Methods: We used Google Trends data (1 Jan 2020 -  30 Mar 2020) to investigate the impact of the pandemic and government measures to curb it on people's concerns, as indexed by changes in search frequency for topics indicating mental distress, social and economic stressors and mental health treatment-seeking. We explored the changes of key topics in Google trends in Italy, Spain, USA, UK, and Worldwide in relation to sentinel events during the pandemic. Results: Globally there appears to be significant concerns over the financial and work-related consequences of the pandemic, with some evidence that levels of fear are rising. Conversely relative searching for topics related to depression and suicide fell after the pandemic was announced, with some evidence that searches for the latter have risen recently. Concerns over education and access to medication appear to be particular social stressors. Whilst searches for face-to-face treatments have declined, those for self-care have risen. Conclusions: Monitoring Google trends shows promise as a means of tracking changing public concerns. In weeks to come it may enable policy makers to assess the impact of their interventions including those aiming to limit negative consequences, such as government funded financial safety nets.

Mapping population mental health concerns related to COVID-19 and the consequences of physical distancing: a Google trends analysis

Background: The 2020 Coronavirus pandemic is a major international public health challenge.  Governments have taken public health protection measures to reduce the spread of the virus through non-pharmalogical measures. The impact of the pandemic and the public health response on individual and population mental health is unknown.  Methods: We used Google Trends data (1 Jan 2020 - 1 Apr 2020) to investigate the impact of the pandemic and government measures to curb it on people's concerns, as indexed by changes in search frequency for topics indicating mental distress, social and economic stressors and mental health treatment-seeking. We explored the changes of key topics in Google trends in Italy, Spain, USA, UK, and Worldwide in relation to sentinel events during the pandemic. Results: Globally there appears to be significant concerns over the financial and work-related consequences of the pandemic, with some evidence that levels of fear are rising. Conversely searching for topics related to depression and suicide fell after the pandemic was announced, with some evidence that searches for the latter have risen recently. Concerns over education and access to medication appear to be particular social stressors. Whilst searches for face-to-face treatments have declined, those for self-care have risen. Conclusions: Monitoring Google trends shows promise as a means of tracking changing public concerns. In weeks to come it may enable policy makers to assess the impact of their interventions including those aiming to limit negative consequences, such as government funded financial safety nets.

Suicide and suicide risk

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

The association between suicide deaths and putatively harmful and protective factors in media reports

BACKGROUND

Exposure to media reporting on suicide can lead to suicide contagion and, in some circumstances, may also lead to help-seeking behaviour. There is limited evidence for which specific characteristics of media reports mediate these phenomena.

METHODS

This observational study examined associations between putatively harmful and protective elements of media reports about suicide in 13 major publications in the Toronto media market and subsequent suicide deaths in Toronto (2011-2014). We used multivariable logistic regression to determine whether specific article characteristics were associated with increases or decreases in suicide deaths in the 7 days after publication, compared with a control window.

RESULTS

From 2011 to 2014, there were 6367 articles with suicide as the major focus and 947 suicide deaths. Elements most strongly and independently associated with increased suicides were a statement about the inevitability of suicide (odds ratio [OR] 1.97, confidence interval [CI] 1.07-3.62), about asphyxia by a method other than car exhaust (OR 1.72, CI 1.36-2.18), about suicide by jumping from a building (OR 1.70, CI 1.28-2.26) or about suicide pacts (OR 1.63, CI 1.14-2.35), or a headline that included the suicide method (OR 1.41, CI 1.07-1.86). Elements most strongly and independently associated with decreased suicides were unfavourable characteristics (negative judgments about the deceased; OR 1.85, CI 1.20-2.84), or mentions of railway (OR 1.61, CI 1.10-2.36) and cutting or stabbing (OR 1.59, CI 1.19-2.13) deaths, and individual murder-suicide (OR 1.50, CI 1.23-1.84).

INTERPRETATION

This large study identified significant associations between several specific elements of media reports and suicide deaths. It suggests that reporting on suicide can have a meaningful impact on suicide deaths and that journalists and media outlets and organizations should carefully consider the specific content of reports before publication.

Profiles by suicide methods: an analysis of older adults

OBJECTIVE

The aim of this study was to investigate choice of suicide method in individuals aged 65 years and over.

METHODS

Data were obtained from the Queensland Suicide Register, Australia. Univariate and multi-variate logistic regression analyses were conducted.

RESULTS

The predominant methods in older adults were hanging (21.5%), firearms and explosives (20.9%), drug poisoning (18.5%), followed by other poisoning (mainly MVCO) (12.6%), suffocation by plastic bag (8.5%), and drowning (6%). Some methods (e.g. firearms and explosives, drug poisoning, suffocation) appeared characterised by profiles (e.g., socio-demographic and clinical aspects), meanwhile others were not well distinguishable. Compared to other methods, those who died by firearms and explosives were significantly more likely to be males, Australian born, live in rural and remote areas, and less likely to have a mental illness, previous suicide attempt(s) or leave a suicide note. Those who died by drug poisoning were more likely to be females, leave a suicide note, experience interpersonal conflict and live in urban areas. Similarly, those who chose suffocation by plastic bag were more likely to be older females, leave a suicide note, and pay attention to suicide in the media, but less likely to experience interpersonal conflict.

CONCLUSION

Acceptability, availability and lethality are important factors impacting choice of means and should be considered when designing suicide prevention activities in older adults.

Suicide deaths by gas inhalation in Toronto: An observational study of emerging methods of suicide

BACKGROUND

Suicide death by gas inhalation has been the subject of global scientific interest due to a rapid increase in the use of helium and charcoal gas for suicide. These may be particularly amenable to means restriction strategies. There has been little scientific attention of this phenomenon in Canada.

METHODS

A review of coroner records was conducted for all suicide deaths in Toronto (1998-2015). Deaths were categorized as due to inhalational asphyxia by compressed gas (i.e. helium or nitrogen), charcoal burning or motor vehicle exhaust, with suicide deaths by other methods as a comparator. Demographic, clinical and suicide specific differences between decedents in these four categories were compared using chi-squared or ANOVA global test of significance with additional pairwise comparisons where appropriate. Secular trends were also examined.

RESULTS

Gas inhalational deaths accounted for 190 (4.7%) of all suicides in Toronto (n = 4062) over the study period and a higher proportion of males used compressed gas or motor vehicle exhaust gases than those who died by other methods (83.3% and 84.0% vs.69.7%, both p = 0.01). Comparing 1998-2003 to 2010-2015 there was a 1075% increase in deaths by helium (4 vs. 43 deaths) and a 533% increase in deaths by charcoal burning (3 vs. 16 deaths) although helium and charcoal burning deaths still accounted for only 4.2% of total suicides 2010-2015. Deaths by helium were more likely to be accompanied by the book "Final Exit" than those by non-inhalational methods (15% vs. 0.7%, p < 0.0001) while 13 of 14 people who died by charcoal burning whose ethnicity could be determined were Asian.

LIMITATIONS

Ethnicity and specific details of procurement of suicide methods were not systematically available in coroner records.

DISCUSSION

Suicide by inhalational asphyxia, particularly by compressed gases, has increased substantially over time in Toronto consistent with observations in other countries. Increased surveillance of these deaths, efforts to restrict access to these methods, and timely interventions including minimizing media reporting are all warranted.

Media Guidelines for Reporting on Suicide: 2017 Update of the Canadian Psychiatric Association Policy Paper

This paper has been substantially revised by the Canadian Psychiatric Association's Research Committee and approved for republication by the CPA's Board of Directors on May 3, 2017. The original policy paper¹ was developed by the Scientific and Research Affairs Standing Committee and approved by the Board of Directors on November 10, 2008.

Has information on suicide methods provided via the Internet negatively impacted suicide rates?

Suicide rates in Germany consistently decreased from 1991 to 2006, but this trend was reversed in 2007. Underlying this reversal were large increases in suicides due to gassing in females and in being overrun in males. During a similar time period (2005-2013), Asian and some Western countries have also observed abrupt increases in suicides due to certain gasses, and the availability of "how-to" information on the Internet about these painless methods of suicide is thought to play a role in their increased use. This study used data from the Federal Statistics Office of Germany to examine current trends in overall suicide mortality in Germany (2007-2015) as well by age, gender, and suicide methods. Also assessed was whether suicides via newly emergent methods are associated with the frequency of corresponding Internet searches using data from Google Trends. Joinpoint regression analyses indicated significant increases in the overall suicide rate (Average Annual Percentage Change (AAPC) = 2.37%) for females, but not males. The largest annual increases were observed in gassing self-intoxication suicides (AAPC = 13.93%), the majority of which involved carbon monoxide. The increase in gassing suicides was larger in females (500%), compared to males (164%). The frequency of suicides by gassing was significantly associated with Internet searches for "carbon monoxide poisoning" for both male and female subgroups, independent of age group. This study provides the updated suicide surveillance data that are necessary for suicide prevention activities. Results are congruent with the recent abrupt rises in carbon monoxide suicides in other countries.

Recent Advances in Means Safety as a Suicide Prevention Strategy

Despite advances in theory and the development and implementation of evidence-based treatments, the United States suicide rate has been rising continuously for over a decade. Although this does not indicate that traditional treatment approaches should be abandoned, it does highlight the need to supplement such approaches with alternatives. One seemingly highly valuable option is means safety, defined as the reduced access to and/or increased safe storage of potentially lethal methods for suicide. This paper provides a review of the current literature on the prevalence of six methods for suicide and preventative efforts aimed to reduce suicide rates. The majority of means safety interventions seem promising given that these methods are common and highly lethal. However, cultural and practical barriers will need to be taken into consideration when implementing these plans. Overall, means safety efforts and preventative measures seem to be promising ways to reduce the national suicide rate if implemented.

Suicide and the Internet: Changes in the accessibility of suicide-related information between 2007 and 2014

BACKGROUND

Following the ongoing concerns about cyber-suicide, we investigate changes between 2007 and 2014 in material likely to be accessed by suicidal individuals searching for methods of suicide.

METHODS

12 search terms relating to suicide methods were applied to four search engines and the top ten hits from each were categorised and analysed for content. The frequency of each category of site across all searches, using particular search terms and engines, was counted.

RESULTS

Key changes: growth of blogs and discussion forums (from 3% of hits, 2007 to 18.5% of hits, 2014); increase in hits linking to general information sites - especially factual sites that detail and evaluate suicide methods (from 9%, 2007 to 21.7%, 2014). Hits for dedicated suicide sites increased (from 19% to 23%), while formal help sites were less visible (from 13% to 6.5%). Overall, 54% of hits contained information about new high-lethality methods.

LIMITATIONS

We did not search for help sites so cannot assess the balance of suicide promoting versus preventing sites available online. Social media was beyond the scope of this study.

CONCLUSIONS

Working with ISPs and search engines would help optimise support sites. Better site moderation and implementation of suicide reporting guidelines should be encouraged.

The association of trends in charcoal-burning suicide with Google search and newspaper reporting in Taiwan: a time series analysis

PURPOSE

Some East/Southeast Asian countries have experienced a rapid increase in suicide by charcoal burning over the past decade. Media reporting and Internet use were thought to contribute to the epidemic. We investigated the association between method-specific suicide incidence and both Internet search volume and newspaper reporting in Taiwan.

METHOD

Weekly data for suicide, suicide-related Google search volume, and the number of articles reporting suicide in four major newspapers in Taiwan during 2008-2011 were obtained. Poisson autoregressive regression models were used to examine the associations between these variables.

RESULTS

In the fully adjusted models, every 10 % increase in Google searches was associated with a 4.3 % [95 % confidence interval (CI) 1.1-7.6 %] increase in charcoal-burning suicide incidence in the same week, and a 3.8 % (95 % CI 0.4-7.2 %) increase in the following week. A one-article increase in the United Daily was associated with a 3.6 % (95 % CI 1.5-5.8 %) increase in charcoal-burning suicide in the same week. By contrast, non-charcoal-burning suicide was not associated with Google search volume, but was associated with the Apple Daily's reporting in the preceding week.

CONCLUSIONS

We found that increased Internet searches for charcoal-burning suicide appeared to be associated with a subsequent increase in suicide by this method. The prevention of suicide using emerging methods may include monitoring and regulating online information that provides details of these methods as well as encouraging Internet service providers to provide help-seeking information.