Cybersuicide: the role of interactive suicide notes on the Internet

Broadcasting Your Death Through Livestreaming: Understanding Cybersuicide Through Concepts of Performance

Cybersuicide, or suicide mediated by the internet in various ways, is a growing phenomenon worldwide and one which makes an often private act highly public. This paper provides an exploration of one version of cybersuicide: suicide that is livestreamed on the internet. Through an analysis of three case studies, this paper asks what light anthropological concepts of performance can shed on cybersuicide? It argues that as a public and social act, cybersuicide needs to be analyzed in terms of how an audience is attracted and retained, as well as the key roles the audience plays in the social practice. This means that cybersuicide has a different structure from suicide offline, impacting how it should be analyzed and understood.

Communication about suicide in YouTube videos: Content analysis of German-language videos retrieved with method-and help-related search terms

Online searches for information on suicide are very common but studies on how the topic is addressed on one of the the most relevant platforms, YouTube, are missing. We performed a content analysis of German-language videos retrieved with the basic term "suicide", a method-related search term ("how to hang yourself"), and a help-related term ("suicide prevention"). We assessed the quality of n=232 randomly selected videos based on media recommendations for suicide reporting. Characteristics of videos retrieved with the method- and help-related search term, were compared to search results for "suicide". Videos retrieved with the help-related term had more potentially protective and fewer harmful characteristics than those retrieved with the other search terms. For example, these videos significantly more often debunked suicide myths and provided contact information to help services. In total, the mean number of harmful and protective characteristics per video were 1.6 and 1.3 for basic searches; 1.7 and 1.0 for method-related searches, and 0.4 and 2.8 for help-related searches, respectively. Videos retrieved in the help-related search were often from help organizations. Only 3% and 8% of videos retrieved with "suicide" and "how to hang yourself", respectively, were age-restricted. Collaborations between suicide prevention and Youtube are warranted to improve the visibility of protective contents and ensure a better implementation of Youtube's own policies regarding self-harm.

Assessing the Usability, Appeal, and Impact of a Web-Based Training for Adults Responding to Concerning Posts on Social Media: Pilot Suicide Prevention Study

BACKGROUND

Suicide prevention remains challenging among youth, as many do not disclose suicidal ideation. Nearly one-third of American Indian and Alaska Native (AI and AN, tribal, or native) youth see concerning messages on social media at least weekly.

OBJECTIVE

To prepare adults to support AI and AN youth who post or view concerning messages, our team designed an hour-long training: Responding to Concerning Posts on Social Media. This study tested the usability, appeal, and impact of the training.

METHODS

A purposive sample of 70 adults was recruited to participate in the pilot, which included 2 study arms. Arm 1 participants completed a 30-min training video and reviewed accompanying handouts, including the Viewer Care Plan (VCP). The VCP provided a 3-step planning and response tool: (1) Start the Conversation, (2) Listen, Gather Information, and Assess Viewer Experience, and (3) Plan and Act. The intent of the VCP was to support and connect AI and AN youth who either view or post concerning messages on social media to life-saving resources. Those enrolled in arm 2 participated in an additional interactive role-play scenario with a coach that took place after the training, via text message. Participants provided qualitative and quantitative feedback on the training's relevance, appeal, and utility. Paired t tests were used to assess confidence in addressing concerning posts between pre- and postsurveys. Content analysis of the role-play transcripts was used to assess the quality and completion of the coached role-plays, in relation to the recommended VCP.

RESULTS

Altogether, 35 participants finished the training and completed pre- and postsurveys; 22 participants completed the 6-month follow-up survey. Pre-post analyses of differences in means found significant improvement across several efficacy measures, including confidence starting a conversation about social media (P=.003), confidence contacting the person who posted something concerning (P<.001), and confidence recommending support services to youth who view (P=.001) or youth who post concerning messages (P<.001). Similarly, pre- to 6-month analyses found significant positive improvement across multiple measures, including confidence contacting the youth who posted (P<.001), confidence starting a conversation about social media with youth (P=.003), and an increase in the number of experiences recommending resources for youth who viewed concerning social media posts (P=.02). Of the 3 steps of the VCP, the least followed step in coached role-plays was sharing tools and resources, which is a part of the third Plan and Act step.

CONCLUSIONS

Findings indicate that the Responding to Concerning Posts on Social Media training is a promising tool to prepare adults to intervene and complete the VCP. Additional evaluation with a larger cohort of participants is needed to determine the unique impact of the role-play scenario and changes in mental health referral rates, behaviors, and skills.

Instances of online suicide, the law and potential solutions

To understand the social and legal issues posed by suicide-related communications over the Internet (messages of threatened suicide and advocated suicide), this article examines a selection of cases involving different types of online baiting and harassment that illustrate different legal and technological issues. The anonymity afforded by computer-mediated communication allows bullies to harass vulnerable individuals and leak (disclose) their personal information. Computer mediation of communication potentially diffuses responsibility; imposes a temporal asynchrony between signified intent and audience response; and reduces the empathy that might motivate observers or witnesses to intervene and render assistance, factors that make online baiting a serious social, legal and technological problem. Potential actions (both legal and technological) for addressing this problem are outlined.

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.

Searching for suicide-related information on Chinese websites

Growing concerns about cyber-suicide have prompted many studies on suicide information available on the web. However, very few studies have considered non-English websites. We aimed to analyze online suicide-related information accessed through Chinese-language websites. We used Taiwan's two most popular search engines (Google and Yahoo) to explore the results returned from six suicide-related search terms in March 2016. The first three pages listing the results from each search were analyzed and rated based on the attitude towards suicide (pro-suicide, anti-suicide, neutral/mixed, not a suicide site, or error). Comparisons across different search terms were also performed. In all, 375 linked webpages were included; 16.3% of the webpages were pro-suicide and 41.3% were anti-suicide. The majority of the pro-suicide sites were user-generated webpages (96.7%). Searches using the keywords 'ways to kill yourself' (31.7%) and 'painless suicide' (28.3%) generated much larger numbers of harmful webpages than the term 'suicide' (4.3%). We conclude that collaborative efforts with internet service providers and search engines to improve the ranking of anti-suicide webpages and websites and implement online suicide reporting guidelines are highly encouraged.

Beneficial and harmful effects of educative suicide prevention websites: randomised controlled trial exploring Papageno v. Werther effects

BackgroundSuicide prevention organisations frequently use websites to educate the public, but evaluations of these websites are lacking.AimsTo examine the effects of educative websites and the moderating effect of participant vulnerability.MethodA total of 161 adults were randomised to either view an educative website on suicide prevention or an unrelated website in a single-blinded randomised controlled trial (trial registration with the American Economic Association's registry: RCT-ID: 000924). The primary outcome was suicidal ideation; secondary outcomes were mood, suicide-prevention-related knowledge and attitudes towards suicide/seeking professional help. Data were collected using questionnaires before (T₁), immediately after exposure (T₂), and 1 week after exposure (T₃) and analysed using linear mixed models.ResultsNo significant intervention effect was identified for the entire intervention group with regard to suicidal ideation, but a significant and sustained increase in suicide-prevention-related knowledge (T₃vT₁P < 0.001, d = 1.12, 95% CI 0.96 to 1.28) and a non-sustained worsening of mood (P < 0.001, T₂vT₁, d = -0.59, -0.75 to -0.43) were observed. Participants with increased vulnerability experienced a partially sustained reduction of suicidal ideation (T₃vT₁, P <0.001, d = -0.34, -0.50 to -0.19).ConclusionsEducative professional suicide prevention websites appeared to increase suicide-prevention-related knowledge, and among vulnerable individuals website exposure may be associated with a reduction of suicidal ideation.

Predictors of psychological improvement on non-professional suicide message boards: content analysis

BACKGROUND

Suicide message boards have been at the core of debates about negative influences of the Internet on suicidality. Nothing is currently known about communication styles that may help users to psychologically improve in these settings.

METHOD

In all, 1182 archival threads with 20 499 individual postings from seven non-professional suicide message boards supporting an 'against-suicide', 'neutral' or 'pro-suicide' attitude were randomly selected and subject to content analysis. Initial needs of primary posters (i.e. individual who open a thread), their psychological improvement by the end of the thread, their responses received and indicators of suicidality were coded. Differences between 'pro-suicide', 'neutral' and 'against suicide' boards, and correlations between primary posters and respondents in terms of suicidality were assessed. Logistic regression was used to test associations with psychological improvement.

RESULTS

'Pro-suicide' boards (n = 4) differed from 'neutral' (n = 1) and 'against-suicide' (n = 2) boards in terms of communicated contents. Indicators of suicidality correlated moderately to strongly between primary posters and respondents on 'pro-suicide' message boards, but less on other boards. Several communicative strategies were associated with psychological improvement in primary posters, including the provision of constructive advice [adjusted odds ratio (aOR) 4.10, 95% confidence interval (CI) 2.40-7.03], active listening (aOR 1.60, 95% CI 1.12-2.27), sympathy towards the poster (aOR 2.22, 95% CI 1.68-2.95) and provision of alternatives to suicide (aOR 2.30, 95% CI 1.67-3.18).

CONCLUSIONS

Respondents resemble primary posters with regard to suicidality in 'pro-suicide' boards, which may hinder psychological improvement. Still, opportunities to intervene in these settings using simple communication techniques exist and need to be taken and evaluated.

Stepping Back From Crisis Points: The Provision and Acknowledgment of Support in an Online Suicide Discussion Forum

Suicide is a global health concern, though little is known about the social practices that might support those who are contemplating suicide. Online forums provide a unique insight into the anonymous discussion of suicide, including sociocultural norms about suicide and the delicate management of online interaction. In this article, we examine the provision and acknowledgment of support in an online discussion forum about suicide, using discursive psychology to analyze the textual interaction. The analysis illustrates how forum threads function as case studies and enable members to gain support on numerous occasions. In this way, members can gain help at crisis points as and when these occur, while still maintaining authenticity as a valid forum member. The analysis also provides additional evidence for models of suicide which highlight the fluid nature of suicidality and contributes to the preventative work on suicide by demonstrating how support can be provided at crisis points.

Social media and suicide prevention: a systematic review

AIM

Social media platforms are commonly used for the expression of suicidal thoughts and feelings, particularly by young people. Despite this, little is known about the ways in which social media can be used for suicide prevention. The aim of this study was to conduct a systematic review to identify current evidence pertaining to the ways in which social media are currently used as a tool for suicide prevention.

METHODS

Medline, PsycInfo, Embase, CINHAL and the Cochrane Library were searched for articles published between 1991 and April 2014. English language articles with a focus on suicide-related behaviour and social media were included. No exclusion was placed on study design.

RESULTS

Thirty studies were included; 4 described the development of social media sites designed for suicide prevention, 6 examined the potential of social media in terms of its ability to reach or identify people at risk of suicide, 15 examined the ways in which people used social media for suicide prevention-related purposes, and 5 examined the experiences of people who had used social media sites for suicide prevention purposes. No intervention studies were identified.

CONCLUSION

Social media platforms can reach large numbers of otherwise hard-to-engage individuals, may allow others to intervene following an expression of suicidal ideation online, and provide an anonymous, accessible and non-judgmental forum for sharing experiences. Challenges include difficulties controlling user behaviour and accurately assessing risk, issues relating to privacy and confidentiality and the possibility of contagion. Social media appears to hold significant potential for suicide prevention; however, additional research into its safety and efficacy is required.

Does Social Belonging to Primary Groups Protect Young People From the Effects of Pro-Suicide Sites?

BACKGROUND

The Internet has facilitated the existence of extreme and pathological communities that share information about ways to complete suicide or to deliberately harm or hurt oneself. This material is user-generated and easily accessible.

AIMS

The present study analyzed the buffering effect of social belonging to a primary group in the situation of pro-suicide site exposure.

METHOD

Cross-national data were collected from the US, UK, Germany, and Finland in spring 2013 and 2014 from respondents aged 15-30 years (N = 3,567). Data were analyzed by using linear regression separately for women and men for each country.

RESULTS

A higher level of belonging to a primary group buffered the negative association of pro-suicide site exposure with mental health, measured as happiness, although the results were not consistent in the subgroups. US male subjects showed a significant buffering effect of the sense of belonging to family while the belonging to friends had a buffering effect among four other subgroups: British female and male subjects and Finnish female and male subjects.

CONCLUSION

The results underline the positive potential of primary groups to shield young people's mental health in the situation of pro-suicide site exposure.

The safety and acceptability of delivering an online intervention to secondary students at risk of suicide: findings from a pilot study

BACKGROUND

Suicide-related behaviour is a major problem among adolescents. Yet relatively few studies have tested the efficacy, acceptability and safety of interventions for this population. We developed and pilot tested an online intervention for at-risk school students, which has led to reduced suicidal ideation, hopelessness and depressive symptoms. The aims of this study were to examine the safety and acceptability of the programme, and to determine which components were found to be most helpful and enjoyable.

METHODS

This pilot study employed a pre-test/post-test design, with an 8-week intervention phase. Participants were assessed immediately before, and immediately after the intervention. Participants were also asked to complete a weekly questionnaire immediately after the intervention, and again 2 days later assessing suicidal ideation and distress.

RESULTS

Twenty-one young people completed the intervention. Overall, the intervention did not lead to increases in suicidal ideation or distress. Participants reported enjoying the programme, in particular watching the video diaries and completing the activities, and said they would recommend the programme to a friend. Overall, the cognitive components of the programme were found to be most helpful.

CONCLUSIONS

Overall, the programme appeared to be a safe and acceptable intervention for at-risk adolescents. This was a small, pilot study so we need to interpret the results with caution. However, the findings are promising and suggest that young people at risk of suicide can safely be included in trials as long as adequate safety procedures are in place. The programme is now being tested in a randomized controlled trial.

Case study of posts before and after a suicide on a Swedish internet forum

Websites and discussion forums have become an important and sometimes controversial source of information on suicide. Using a case report, our aim was to examine the responses, attitudes and beliefs that were communicated on a forum before, during and after a suicide act. We undertook two related analyses: a qualitative investigation of the messages that were posted before the suicide and a combined qualitative-quantitative analysis of the messages posted during and after the suicide. Nearly half the posted messages before the suicide encouraged the victim to complete the suicidal act, and a surprising number of posts after the suicide expressed excitement, although around half of the posts considered the suicide to be tragic. It is of great importance to increase awareness of suicide signals and understanding about how to respond to individuals who communicate suicide intentions on different forums on the internet.

Suicide-related Internet use: A review

OBJECTIVE

To systematically review research on how people use the Internet for suicide-related reasons and its influence on users. This review summarises the main findings and conclusions of existing work, the nature of studies that have been conducted, their strengths and limitations, and directions for future research.

METHOD

An online search was conducted through PsycINFO, PubMed, Ovid MEDLINE and CINAHL databases for papers published between 1991 and 2014. Papers were included if they examined how the Internet was used for suicide-related reasons, the influence of suicide-related Internet use, and if they presented primary data, including case studies of Internet-related suicide attempts and completions.

RESULTS

Findings of significant relationships between suicide-related search trends and rates of suicide suggest that search trends may be useful in monitoring suicide risk in a population. Studies that examine online communications between people who are suicidal can further our understanding of individuals' suicidal experiences. While engaging in suicide-related Internet use was associated with higher levels of suicidal ideation, evidence of its influence on suicidal ideation over time was mixed. There is a lack of studies directly recruiting suicidal Internet users. Only case studies examined the influence of suicide-related Internet use on suicidal behaviours, while no studies assessed the influence of pro-suicide or suicide prevention websites. Online professional services can be useful to suicide prevention and intervention efforts, but require more work in order to demonstrate their efficacy.

CONCLUSIONS

Research has shown that individuals use the Internet to search for suicide-related information and to discuss suicide-related problems with one another. However, the causal link between suicide-related Internet use and suicidal thoughts and behaviours is still unclear. More research is needed, particularly involving direct contact with Internet users, in order to understand the impact of both informal and professionally moderated suicide-related Internet use.

Social media and suicide prevention: findings from a stakeholder survey

BACKGROUND

Suicide is a leading cause of death, particularly among young adults. The rapid growth of social media and its heavy use by young adults presents new challenges and opportunities for suicide prevention. Social media sites are commonly used for communicating about suicide-related behavior with others, which raises the possibility of using social media to help prevent suicide. However, the use of social media varies widely between different suicide prevention advocates. The role this type of intervention should play in a community's overall suicide prevention strategy remains a matter of debate.

AIM

Explore the ways in which stakeholders use social media for suicide prevention and assess their views about the potential utility of social media as a suicide prevention tool.

METHODS

A 12-week stakeholder consultation that involved the online administration and completion of surveys by 10 individuals who conduct research about suicide and social media, 13 organizations that use social media for suicide prevention purposes, and 64 users of social media.

RESULTS

Social media was seen as a useful means of delivering a range of suicide prevention activities. Respondents reported that the key benefits of social media were the opportunity to obtain emotional support from others, to express one's feelings, to talk to others with similar problems, and to provide help to others. The social media site believed to hold most potential for delivering suicide prevention activities was Facebook. There were concerns about potential risks of social media, but respondents felt the potential benefits outweighed the risks.

CONCLUSIONS

Social media was recognized by different types of stakeholders as holding potential for delivering suicide prevention activities. More research is required to establish the efficacy and safety of potential social media-based interventions and ethical standards and protocols to ensure that such interventions are delivered safely need to be developed and implemented.

E-suicide note: A newer trend and its medico-legal implications in India

Rapid advancements of information and communication technology in the form of electronic mails, mobile phones, social networking sites, etc have an increasing impact on people's day to day life. It has been observed that these readily available applications are used frequently to express suicidal intentions. There are many studies on conventional handwritten suicide notes but suicide note in electronic format is an emerging issue and an under-researched phenomena. The authors have termed it as "E-suicide note" and discuss its medico-legal implications in India with examples from their observations.

Suicídio e internet: análise de resultados em ferramentas de busca

Embora seja ainda um assunto incipiente no Brasil, a mídia pode exercer influência sobre diferentes atitudes dos sujeitos e, especificamente, sobre suicídio. Este estudo buscou replicar, com adaptações, uma pesquisa inglesa sobre conteúdos relacionados ao suicídio acessados na internet. Foram utilizadas, em três sites de busca, doze expressões-chave, como por exemplo, suicídio; métodos de suicídio; suicídio indolor; suicídio rápido entre outras. Foram analisadas as dez primeiras indicações de cada pesquisa; retirando-se os resultados repetidos, a amostra foi composta por 209 sites. A análise do conteúdo das páginas eletr™nicas se pautou em 19 critérios de classificação, sendo os de maior frequência os sites acadêmicos; os de conteúdo religioso; o que retratam o suicídio em termos elegantes; e os sites mantidos por psicólogos ou profissionais de saúde. Como conclusão, observou-se que, diferente do descrito no artigo original, no Brasil não foram encontradas páginas com conteúdo pró-suicídio, promovendo, encorajando ou facilitando atos suicidas.

The representation of suicide on the Internet: implications for clinicians

Background

Suicide is one of the major causes of death in the world, leading to approximately 1 million deaths per year. While much of what is said about suicide and its causes is still taboo in most contemporary societies and cultures, internet websites and discussion forums have become an important and controversial source of information on the subject. A great deal of ambivalence is discernible as to whether online communication about suicide primarily should be seen as an opportunity or a serious threat.

Objective

To investigate how the subject of suicide is represented on the Internet, based on hits generated by the search engine Google.

Methods

In an exploratory design, Google search results on the target word “suicide”, for the years 2005, 2009, and 2012 respectively, were systematically analyzed and compared.

Results

The study shows that web pages of institutional origin on the subject predominate, that the content provided by these institutions concerns primarily research and prevention, and that the form of communication used by these senders is almost exclusively monological. However, besides these institutional pages there are a substantial number of private senders and pages, often anti-medical and against treatment of depression and other mental problems, characterized by dialogue, confessions and narratives, and to a higher degree, an alternative pro-suicide stance.

Conclusions

To counteract the influence of anti-medical and pro-suicide information, the role of the Internet should be discussed with the patient in clinical practice. Dialogical and confessional communications provide an opportunity for the clinician to gain a deeper perspective into perceptions of patients, regarding both their afflictions and the role of medical treatment in their lives.

Social media and suicide: a public health perspective

There is increasing evidence that the Internet and social media can influence suicide-related behavior. Important questions are whether this influence poses a significant risk to the public and how public health approaches might be used to address the issue. To address these questions, we provide an overview of ways that social media can influence suicidal behavior, both negatively and positively, and we evaluate the evidence of the risk. We also discuss the legal complexities of this important topic and propose future directions for research and prevention programs based on a public health perspective.

Internet suicide searches and the incidence of suicide in young people in Japan

Although several case reports have suggested a relationship between accessing Internet suicide sites and the incidence of suicide, the influence of the Internet on the incidence of suicide is not known. Thus, we examined the association between Internet suicide-related searches and the incidence of suicide in 20- and 30-year-old individuals in Japan. The Box-Jenkins transfer function model was applied to monthly time series data from January 2004 to May 2010 (77 months). The terms "hydrogen sulfide," "hydrogen sulfide suicide," and "suicide hydrogen sulfide suicide" at (t-11) were related to the incidence of suicide among people aged in their 20 s (P = 0.005, 0.005, and 0.006, respectively) and people aged in their 30 s (P = 0.013, 0.011, and 0.012, respectively). "BBS on suicide" at (t-5) and "suicide by jumping" at (t-6) were related to the incidence of suicide in people aged 30-39 (P = 0.006 and 0.001, respectively). Internet searches for specific suicide-related terms are related to the incidence of suicide among 20- and 30-year-old individuals in Japan. Routine interrogation by a clinician about visiting Internet suicide websites and stricter regulation of these websites may reduce the incidence of suicide among young people.

Information sources used by the suicidal to inform choice of method

BACKGROUND

Choice of suicide method strongly influences the outcome of an attempt. Public knowledge of possible methods is an important but less frequently considered aspect of the accessibility of suicide. This qualitative study explored the sources of information shaping the near-fatal suicide attempts of 22 individuals.

METHODS

Respondents were recruited from nine hospitals in England. Semi-structured interviews were conducted to gain detailed narratives of the planning of the suicide attempt. Interviews were recorded, transcribed, then subjected to thematic analysis utilising constant comparison techniques.

RESULTS

Information sources discussed most frequently were television, news stories, the Internet, and previous self-harm. Others were professional resources, personal knowledge of others' attempts and information gleaned from healthcare professionals. Many respondents reported seeing media portrayals or reports of suicide, which had contributed to their awareness of suicide methods. Several provided examples of direct imitation. Some had deliberately sought information about methods when planning their attempt--mostly from the Internet. Past experience was used to identify 'best' methods and perfect implementation.

LIMITATIONS

The frequency with which sources of information are 'used' by particular groups and their relative import cannot be inferred from a qualitative sample. Near-fatal cases may differ from completed suicides.

CONCLUSIONS

The media is an important contributor to the cognitive availability of suicide in society and could be used for prevention through carefully crafted portrayals of suicide designed to generate negative social perceptions of popular methods. Understanding of how sources of information can influence perceptions of suicide could inform the content of clinical conversations with patients.

Factors influencing suicidal ideation among Japanese adults: from the national survey by the Cabinet Office

AIM

Suicide prevention is of pressing importance in Japan, and grappling with this problem necessitates clarifying the causes of suicidal ideation. The purpose of the present study was to investigate several factors influencing suicidal ideation. This was done through analyzing factors examined in prior research and accessing suicide sites.

METHODS

A total of 1080 randomly selected adults were asked about stress, stress release, social support sources, depression, access of suicides sites, and suicidal ideation.

RESULTS

Around 6% of men in their 20s and 30s as well as 7% of people with suicide ideations had accessed suicide sites on the web. Those with suicide ideations were more likely to access suicide sites than those without. There was no sex difference in suicide ideations. The results concerning factors influencing past-year suicide ideations revealed that there were age and sex differences in these factors.

CONCLUSION

For men in their 20s through their 50s, accessing suicide sites influenced suicidal ideations through depression, and for women in the same age bracket, emotional support influenced suicidal ideations through depression. For men and women over the age of 60, depression strongly influenced suicidal ideations.

Two UK suicides using nicotine extracted from tobacco employing instructions available on the Internet

Tobacco is one of the most easily accessible and commonly abused drugs world-wide. Nicotine, one of its principal constituents, can cause serious or fatal overdoses. Whilst the deliberate ingestion of this substance appears to be relatively rare, often the important signs of its consumption are not recognised, sometimes with fatal results. Here we describe two cases of intentional fatal ingestion of nicotine. The nicotine was extracted from tobacco using instructions available on the Internet. The first case involved a male aged 19 who died in 2008. The post-mortem blood and urine levels of nicotine were 5.5mg/l and >80 mg/l respectively; the blood level is in line with the generally recognised fatal level of >5mg/l. The levels of nicotine's main metabolite, cotinine, for this case were 2.5mg/l and 7.9 mg/l for blood and urine respectively. A comparative case in 1999 involved a 32 year-old male. The level of post-mortem nicotine in his blood was 1.0mg/l. These are believed to be the first UK suicides by nicotine using instructions from the Internet reported in the literature. Information that nicotine was the agent responsible only became apparent some time after death. There may be more deaths due to this cause that go unrecognised because quantification of nicotine and cotinine levels is not often conducted, due to the wide prevalence of smoking. It is important that all evidence at the scene of a sudden and unexplained death is carefully evaluated, including potential clues on PCs and lap-tops.

Patient-targeted googling: the ethics of searching online for patient information

With the growth of the Internet, psychiatrists can now search online for a wide range of information about patients. Psychiatrists face challenges of maintaining professional boundaries with patients in many circumstances, but little consideration has been given to the practice of searching online for information about patients, an act we refer to as patient-targeted Googling (PTG). Psychiatrists are not the only health care providers who can investigate their patients online, but they may be especially likely to engage in PTG because of the unique relationships involved in their clinical practice. Before searching online for a patient, psychiatrists should consider such factors as the intention of searching, the anticipated effect of gaining information online, and its potential value or risk for the treatment. The psychiatrist is obligated to act in a way that respects the patient's best interests and that adheres to professional ethics. In this article, we propose a pragmatic model for considering PTG that focuses on practical results of searches and that aims to minimize the risk of exploiting patients. We describe three cases of PTG, highlighting important ethical dilemmas in multiple practice settings. Each case is discussed from the standpoint of the pragmatic model.

The use of the Internet for counseling the suicidal individual: possibilities and drawbacks

The role of the Internet in facilitating and preventing suicide is reviewed. Two online suicide prevention programs are described: SAHAR in Israel and Befrienders worldwide. Examples are provided of crisis intervention by e-mail. Finally, some caveats are presented based on experiences with crisis intervention by telephone.

Suicide prevention by online support groups: an action theory-based model of emotional first aid

In the last two decades, online support groups have become a valuable source of help for individuals in suicidal crisis. Their attractiveness is attributed to features that enhance help-seeking and self-disclosure such as availability, anonymity, and use of written communication. However, online support groups also suffer from limitations and potential risks as agents of suicide prevention. The Israeli Association for Emotional First Aid (ERAN) has developed a practical model that seeks to maximize the benefits and minimize the risks of online suicide prevention. The model applies the Action Theory concepts whereby individuals shape their own environment. The present paper presents the model, which is based on an online support group combined with personal chat and a telephonic help line. The online support group is moderated by paraprofessionals who function as both process regulators and support providers. The principles and practice of the model are described, the theoretical rationale is presented, and directions for future research are suggested.

Understanding self-harm and suicide websites: a qualitative interview study of young adult website users

Self-harm and suicide websites have been heavily criticized both in the literature and the wider media, despite the fact that very little is known about them. To date, no study has interviewed users of these sites about them. This qualitative study aims to explore the accounts of young adults who engage in self-harming and suicidal behaviors and use websites dedicated to these issues, in order to develop a broader understanding of these websites and to identify potential implications for future research. In-depth interviews were conducted via e-mail with 10 participants, who were recruited directly from self-harm and suicide websites. Using discourse analysis, we identified three main ways in which participants wrote about the sites. They constructed them as sources of empathy and understanding, as communities, and as a way of coping with social and psychological distress. These discourses gave users access to important, socially valued identities, such as being understood, belonging to a community and coping with their problems. If health professionals and researchers hope to understand people who use self-harm and suicide websites, and engage them in their services, they must take a more balanced view and not focus solely on the possible risks associated with using such sites.

Internet message boards for suicidal people: a typology of users

Clinical psychological discourse contains a varied array of evaluations of the risks and/or benefits of Internet message boards where people can discuss their suicidal thoughts. Public opinion contends they are harmful. To assess this assumption, an online questionnaire (N = 164) survey was conducted on a German message board for suicidal people. Three user types were identified with differing motives for visiting the forum and different usage effects of the message board. The results contradict the assumptions that suicide message boards are generally a source of potential harm and that they foster suicidal tendencies and point instead to their predominantly constructive or even suicide-preventive functions.

Suicide and the internet

Recentreports of suicide by young people have highlighted the possible influence of internet sites. Lucy Biddle and colleagues investigate what a web search is likely to find

Telecommunication and suicide prevention: hopes and challenges for the new century

Development of information technology has created new opportunities and challenges in suicide prevention, research, and clinical practice. This article presents an overview of the wide range of telecommunication-based suicide prevention approaches. Interventions using the Internet, telephone, and videoconferencing are discussed, including crisis intervention, referral, and support, suicide risk assessment, psychotherapy for individuals at risk, and online-based suicide prevention training and education. Research regarding effectiveness of telecommunication-based suicide prevention in various demographic and clinical populations is reviewed, as well as concerns regarding this type of intervention. Future areas of research and development in the use of telecommunication media in prevention of suicide are discussed.

A suicide in an online mental health support group: reactions of the group members, administrative responses, and recommendations

Suicides in online mental health support groups are inevitable. This case report of such a suicide describes the responses of the group members and the moderator and makes recommendations. Members of a large, public, mental health message board supported each other, and the moderator, a mental health professional, managed the milieu. A member joined in February 2001 and killed herself in April 2002. The initial response of the members was grief. The moderator attempted to minimize suicide contagion by not making any special announcements and to facilitate mourning by starting a memorial thread. There were no reports of self-injury in response to the suicide, and the online ventilation of grief may in fact have had some preventative effect. One member went to the funeral, and gradually, the group moved on. The moderator later implemented a memorial page. The responses of online groups to suicide may, like those of real-life groups, have resuscitation, rehabilitation, and renewal phases. Diffusion of dependency, a searchable archive, and threaded, asynchronous discussion may facilitate mourning, but anonymity may increase vulnerability to false reports. A thread started in memory of a deceased member may function like a virtual memorial service. A memorial page may function like a virtual cemetery. Preliminary recommendations can be made regarding suicide prevention and responding to suicide in moderated online mental health support groups.

Ethical, legal, and practical issues in the control and regulation of suicide promotion and assistance over the Internet

The promotion of suicide and description of suicide methods on the Internet have led to widespread concern that legal control is mandated. Apart from value concerns pertaining to attitudes about suicide, the guarantee of freedom of expression presents a serious challenge to the introduction of restrictive laws. Recent developments in Australia and Europe are presented, noting jurisdictional complexity as an obstacle to effective application. Finally, scientific data of an epidemiological nature are revealed to be insufficient to warrant making causal assertions about the Internet and its relation to suicidal acts, including those of vulnerable populations. Recommendations are made with respect to public education, suicide prevention, and future research.

Emotional first aid for a suicide crisis: comparison between Telephonic hotline and internet

The telephone and the internet have become popular sources of psychological help in various types of distress, including a suicide crisis. To gain more insight into the unique features of these media, we compared characteristics of calls to three technologically mediated sources of help that are part of the volunteer-based Israeli Association for Emotional First Aid (ERAN): Telephonic hotline (n = 4426), personal chat (n = 373) and an asynchronous online support group (n = 954). Threats of suicide were much more frequent among participants in the asynchronous support group than the telephone and personal chat. These findings encourage further research into suicide-related interpersonal exchanges in asynchronous online support groups.

[Suicidality and the Internet. Danger from new media]

The Internet has a powerful effect on society and thereby also on psychiatric patients. It offers suicide prevention services but also is a source of information and exchange of thoughts on how to commit suicide. This paper describes an 18-year-old female who learned about methods of suicide in the Internet and then ordered barbiturates. She survived because of early intervention.

Suizidselbsthilfe-Foren im Internet: Eine Befragungsstudie

Zusammenfassung. Theoretischer Hintergrund: Im klinischen Diskurs ist die Beurteilung der Gefahren bzw. des Nutzens von Internetdiskussionsgruppen, in denen sich Menschen mit suizidalen Gedanken austauschen, sehr heterogen. Es überwiegen aber Stimmen, die von einer immensen Schädlichkeit dieser Foren ausgehen und die im extremsten Fall staatliche Maßnahmen zur Schließung der Foren fordern. Methode: Um spekulativen Annahmen über die Funktionen dieser “Suizidforen“ empirische Evidenz gegenüberzustellen, wurde in einem deutschsprachigem Forum für Suizidgefährdete eine Online-Befragungsstudie (N = 164; je 50% männlich bzw. weiblich; 88% ≤ 30 Jahre) durchgeführt. Ergebnisse: Es ließen sich drei Nutzertypen bestimmen (der “konstruktiv Hilfesuchende“, der “ambivalent Hilfesuchende“, der “unspezifisch Motivierte“), die sich mit hohen Effektstärken hinsichtlich ihrer Motive ein solches Forum aufzusuchen als auch in den klinisch relevanten Auswirkungen der Teilnahme an einer solchen Community unterschieden. Schlussfolgerungen: In ihrer Gesamtheit widersprechen die vorliegenden Ergebnisse deutlich der Annahme, “Suizid-Foren“ im Internet stellten pauschal ein Gefährdungspotenzial dar.

Writing characteristics of suicidal people on the Internet: a psychological investigation of emerging social environments

Three studies were carried out to investigate the writings of suicidal people on the Internet, hypothesizing consistent findings to equivalent research of offline writing. In Study 1, suicidal persons' (n = 34) attributions as the cause of their condition, as expressed in their free online writing, were compared to those of emotionally distressed, nonsuicidal (n = 16) and to nondistressed (n = 15) individuals. Results showed that suicidal persons have significantly more stable and global attributions than do the other groups. In Study 2, expressions of self-focus in online written messages were compared among suicidal, two levels of nonsuicidal but distressed, and nondistressed individuals (200 messages in each group). With the use of various expressions of self-focus, findings showed that suicidal people were distinctively self-focused in their writing, unlike their counterparts. In Study 3, psychologically relevant themes in the online writing of suicidal (n = 39) and highly distressed, nonsuicidal persons (n = 24) were compared. Results revealed that the former expressed significantly more unbearable psychological pain and cognitive constriction than did the latter. The findings of the three studies are consistent with those found in examinations of offline writing. The research has important implications for the use of online environments for psychological research and means for assessment, as well as for understanding suicidality.

Jugendliche in stationärer psychiatrischer Behandlung: Parasuizidale Symptome und psychische Störungen

Zusammenfassung. Psychische Störungen zählen zu den wichtigsten Ursachen für Parasuizide und Suizide. Dies gilt für das Erwachsenenalter und mit gewissen Abstrichen auch für das Jugendalter. Die häufigsten psychischen Störungen im Zusammenhang mit Suizidalität im Jugendalter sind akute Belastungsreaktionen, affektive Störungen, Substanzmissbrauch sowie Borderline-Syndrome und andere beginnende Persönlichkeitsstörungen. Essstörungen und Schizophrenien sind dagegen im Jugendalter noch nicht mit erhöhten Parasuiziden verknüpft. Anhand einer Gesamtstichprobe von 537 konsekutiv aufgenommenen und nach ICD-10 diagnostizierten stationär behandelten jugendpsychiatrischen Patienten konnten 163 mit parasuizidalen Symptomen bei Aufnahme ermittelt werden, die etwa zur Hälfte aus parasuizidalen Gedanken und parasuizidalen Handlungen bestanden. Der Anteil parasuizidaler Jugendlicher auf der Aufnahmestation lag bei etwa 66 %, auf der Therapiestation (Rottmannshöhe) bei etwa 30 %. Dies spricht für die Relevanz von Selektionsfaktoren bei Häufigkeits- und vermutlich auch Schweregradangaben von Suizidalität im stationären jugendpsychiatrischen Bereich.

Cybersuizid oder Werther-Effekt online: Suizidchatrooms und -foren im Internet

Zusammenfassung. Die Beratung der Medien zur Verhinderung von Imitationssuiziden hat einen festen Stellenwert in der Suizidprävention. Das zunehmend an Bedeutung gewinnende Internet birgt für vulnerable Jugendliche mit Suizidgedanken sowohl zusätzliche Gefahren als auch erweiterte Möglichkeiten des Austauschs. In speziellen Chatrooms nehmen suizidgefährdete respektive suizidinteressierte Jugendliche Kontakt miteinander auf, wodurch Suizidalität ausagiert und reduziert, aber auch aufrechterhalten und potenziert werden könnte. Wissenschaftliche Untersuchungen sind dringend notwendig, um mediale Effekte des Internets objektiv zu erfassen. Implikationen für die Praxis sind unter anderem Kenntnisse von Bezugspersonen, Ärzten und Psychotherapeuten über Suizid-Chatrooms, die Forderung nach Einhaltung internetspezifischer Presserichtlinien, international geltende Gesetze sowie suffiziente Online-Informationen und Hilfeangebote für gefährdete Jugendliche.

A dose-response relationship between imitational suicides and newspaper distribution

Although the Werther effect is well known, up to now a correlation between the differential distribution of particular media reports and subsequent imitational suicides could not be found. This study investigates a celebrity suicide by gun in Austria, which led to extensive reports in the largest Austrian newspaper, whose distribution shows substantial regional differences. The numbers of suicides by firearm in the 3 weeks after the reporting showed an increase over the 3 weeks prior. Regional analysis revealed a strong correlation of suicides by firearm and distribution of the newspaper (log odds ratios; r(9) = .62; p = .04, one-tailed). This dose-response effect explains 40% of the variability of changes. These results underline the influence of media reports on suicidal behavior.