Examining community-level protection from Alaska Native suicide: An Indigenous knowledge-informed extension of the legacy of Michael Chandler and Christopher Lalonde

Chandler and Lalonde broadened the scope of inquiry in suicide research by providing theoretical grounding and empirical support for the role of community, culture, and history in understanding Indigenous youth suicide and reimagining its prevention. Their work pushed the field to consider the intersectional process of individual and collective meaning-making in prevention of Indigenous suicide, together with the central role culture plays in bringing coherence to this process over time. Their innovation shifted the research focus to include the shared histories, contexts, and structures of meaning that shape individual lives and behaviors. We describe here a new generation of research extending their pathbreaking line of inquiry. Recent work aims to identify complex associations between community-level structures and suicidal behavior by collaborating with Alaska Native people from rural communities to describe how community protective factors function as preventative resources in their daily lives. Community engagement and knowledge co-production created a measure of community protection from suicide. Structured interviews with rural Alaska Native community members allowed use of this measure to produce relevant, accessible, and actionable knowledge. Ongoing investigations next seek to describe their mechanisms in shaping young people's lives through a multilevel, mixed-methods community-based study linking community-level protection to protection and well-being of individual youth. These efforts to understand the multiple culture-specific and culturally mediated pathways by which communities build on their strengths, resources, and practices to support Indigenous young people's development and reduce suicide risk are inspired by and expand on Chandler and Lalonde's remarkable legacy.

Implementation of Complex Suicide Prevention Interventions: Insights into Barriers, Facilitators and Lessons Learned

INTRODUCTION

Effective suicide prevention interventions are infrequently translated into practice and policy. One way to bridge this gap is to understand the influence of theoretical determinants on intervention delivery, adoption, and sustainment and lessons learned. This study aimed to examine barriers, facilitators and lessons learned from implementing complex suicide prevention interventions across the world.

METHODS AND MATERIALS

This study was a secondary analysis of a systematic review of complex suicide prevention interventions, following updated PRISMA guidelines. English published records and grey literature between 1990 and 2022 were searched on PubMed, CINAHL, PsycINFO, ProQuest, SCOPUS and CENTRAL. Related reports were organized into clusters. Data was extracted from clusters of reports on interventions and were mapped using the updated Consolidated Framework for Implementation Research.

RESULTS

The most frequently-reported barriers were reported within the intervention setting and were related to the perceived appropriateness of interventions within settings; shared norms, beliefs; and maintaining formal and informal networks and connections. The most frequently reported facilitators concerned individuals' motivation, capability/capacity, and felt need. Lessons learned focused on the importance of tailoring the intervention, responding to contextual needs and the importance of community engagement throughout the process.

CONCLUSION

This study emphasizes the importance of documenting and analyzing important influences on implementation. The complex interplay between the contextual determinants and implementation is discussed. These findings contribute to a better understanding of barriers and facilitators salient for implementation of complex suicide prevention interventions.

Centering Community Strengths and Resisting Structural Racism to Prevent Youth Suicide: Learning from American Indian and Alaska Native Communities

The persistence of extreme suicide disparities in American Indian and Alaska Native (AI/AN) youth signals a severe health inequity with distinct associations to a colonial experience of historical and on-going cultural, social, economic, and political oppression. To address this complex issue, we describe three AI/AN suicide prevention efforts that illustrate how strengths-based community interventions across the prevention spectrum can buffer suicide risk factors associated with structural racism. Developed and implemented in collaboration with tribal partners using participatory methods, the strategies include universal, selective, and indicated prevention elements. Their aim is to enhance systems within communities, institutions, and families by emphasizing supportive relationships, cultural values and practices, and community priorities and preferences. These efforts deploy collaborative, local approaches, that center on the importance of tribal sovereignty and self-determination, disrupting the unequal power distribution inherent in mainstream approaches to suicide prevention. The examples emphasize the centrality of Indigenous intellectual traditions in the co-creation of healthy developmental pathways for AI/AN young people. A central component across all three programs is a deep commitment to an interdependent or collective orientation, in contrast to an individual-based mental health suicide prevention model. This commitment offers novel directions for the entire field of suicide prevention and responds to calls for multilevel, community-driven public health strategies to address the complexity of suicide. Although our focus is on the social determinants of health in AI/AN communities, strategies to address the structural violence of racism as a risk factor in suicide have broad implications for all suicide prevention programming.

The impact of the global COVID-19 pandemic on risk factors for suicide in healthcare workers: A narrative review

BACKGROUND

Suicide is a leading cause of death in the United States. Worldwide, over 700,000 people die by suicide each year. Healthcare workers are more vulnerable to suicide risk factors than the general population. The global COVID-19 pandemic presents additional workplace and health concerns that relate to suicide risk factors in healthcare workers. It is important to recognise suicide risk factors in healthcare workers and to implement strategies to reduce these risk factors.

OBJECTIVES

This study describes the impact of the global COVID-19 pandemic on risk factors for suicide in healthcare workers and identifies evidence-based strategies and resources to reduce suicide risk factors in healthcare workers.

DESIGN

The authors conducted a thematic analysis and narrative review of the literature.

METHODS

Using health science databases, the authors searched the literature, selected and analyzed studies, identified themes, synthesised findings and created a narrative review. The STROBE checklist was used in this study.

RESULTS

Two themes were identified (1) The impact of the COVID-19 pandemic on work-related suicide risk factors in healthcare workers; (2) The impact of the COVID-19 pandemic on mental health-related suicide risk factors in healthcare workers. The pandemic has affected suicide risk factors in healthcare workers. Many studies discussed evidence-based strategies and resources that can be used to reduce suicide risk factors.

CONCLUSION

The global COVID-19 pandemic has negatively impacted suicide risk factors in healthcare workers. It is time for individuals and healthcare delivery systems to implement suicide risk prevention strategies to protect healthcare workers now and in the future.

RELEVANCE TO CLINICAL PRACTICE

This review increases awareness of the pandemic's impact on healthcare workers' risk factors for suicide and identifies evidence-based suicide risk prevention strategies and resources for healthcare workers.

PATIENT OR PUBLIC CONTRIBUTION

Library services supported this research by generating search strategies and providing resources and tools.

Re-constructing parental identity after parents face their offspring's suicidal behaviour: An interview study

INTRODUCTION

Parents are affected when their offspring engages in non-fatal suicidal behaviour. Although research exists on parents' mental and emotional state when they realise this behaviour, relatively little attention has been devoted to exploring how their parental identity is affected.

PURPOSE

To explore how parents re-constructed and negotiated their parental identity after realising that their offspring was suicidal.

METHOD

A qualitative exploratory design was adopted. We conducted semi-structured interviews with 21 Danish parents who self-identified as having offspring at risk of suicidal death. Interviews were transcribed, analysed thematically and interpreted by drawing on the interactionist concepts of negotiated identity and moral career.

FINDINGS

Parents' perspectives on their parental identity were conceptualised as a moral career encompassing three distinct stages. Each stage was negotiated through social interaction with other people and the wider society. Entry into the first stage, disrupted parental identity, occurred when parents realised that they could lose their offspring to suicide. At this stage, parents trusted their own abilities to resolve the situation and keep their offspring safe and alive. This trust was gradually undermined by social encounters, which caused career movement. In the second stage, impasse, parents lost faith in their ability to help their offspring and to change the situation. Whereas some parents gradually resigned entirely to impasse, others regained their trust in their own abilities through social interaction in the third stage, restored parental agency.

CONCLUSION

Offspring's suicidal behaviour disrupted parents' self-identity. Social interaction was fundamental if parents were to re-construct their disrupted parental identity. This study contributes with knowledge about the stages characterising the reconstructive process of parents' self-identity and sense of agency.

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

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

Prevention of suicidal behavior in older people: A systematic review of reviews

Older people have the highest rates of suicide, yet the evidence base on effective suicide preventions in late-life is limited. This systematic review of reviews aims to synthesize data from existing reviews on the prevention and/or reduction of suicide behavior in late-life and evidence for effectiveness of interventions. A systematic database search was conducted in eight electronic databases from inception to 4/2020 for reviews targeting interventions among adults ≥ 60 to prevent and/or reduce suicide, suicide attempt, self-harm and suicidal ideation. Four high quality reviews were included and interventions categorized as pharmacological (antidepressant use: 239 RCTs, seven observational studies) and behavioral (physical activity: three observational studies, and multifaceted primary-care-based collaborative care for depression screening and management: four RCTs). The 2009 antidepressant use review found significant risk reduction for suicide attempt/self-harm (OR = 0.06, 95% CI 0.01-0.58) and suicide ideation (OR = 0.39, 95% CI 0.18-0.78) versus placebo. The 2015 review found an increased risk of attempts with antidepressants versus no treatment (RR = 1.18, 95% CI 1.10-1.27) and no statistically significant change in suicides versus no treatment (RR = 1.06, 95% CI 0.68-1.66) or ideation versus placebo (OR = 0.52, 95% CI 0.14-1.94). Protective effects were found for physical activity on ideation in 2 out of 3 studies when comparing active versus inactive older people. Collaborative care demonstrated significantly less attempts/ideation (OR = 0.80, 95% CI 0.68-0.94) in intervention group versus usual care. The results of this review of reviews find the evidence inconclusive towards use of antidepressants for the prevention of suicidal behavior in older people, thus monitoring is required prior to start, dosage change or cessation of antidepressants. Evidence to date supports physical activity and collaborative management for reduction of suicide ideation, but additional trials are required for a meta-analysis. To build on these findings, continued high-quality research is warranted to evaluate the effectiveness of interventions in late life.

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.

Using Administrative Data to Predict Suicide After Psychiatric Hospitalization in the Veterans Health Administration System

There is a very high suicide rate in the year after psychiatric hospital discharge. Intensive postdischarge case management programs can address this problem but are not cost-effective for all patients. This issue can be addressed by developing a risk model to predict which inpatients might need such a program. We developed such a model for the 391,018 short-term psychiatric hospital admissions of US veterans in Veterans Health Administration (VHA) hospitals 2010-2013. Records were linked with the National Death Index to determine suicide within 12 months of hospital discharge (n=771). The Super Learner ensemble machine learning method was used to predict these suicides for time horizon between 1 week and 12 months after discharge in a 70% training sample. Accuracy was validated in the remaining 30% holdout sample. Predictors included VHA administrative variables and small area geocode data linked to patient home addresses. The models had AUC=.79-.82 for time horizons between 1 week and 6 months and AUC=.74 for 12 months. An analysis of operating characteristics showed that 22.4%-32.2% of patients who died by suicide would have been reached if intensive case management was provided to the 5% of patients with highest predicted suicide risk. Positive predictive value (PPV) at this higher threshold ranged from 1.2% over 12 months to 3.8% per case manager year over 1 week. Focusing on the low end of the risk spectrum, the 40% of patients classified as having lowest risk account for 0%-9.7% of suicides across time horizons. Variable importance analysis shows that 51.1% of model performance is due to psychopathological risk factors accounted, 26.2% to social determinants of health, 14.8% to prior history of suicidal behaviors, and 6.6% to physical disorders. The paper closes with a discussion of next steps in refining the model and prospects for developing a parallel precision treatment model.

Re-Thinking Ethics and Politics in Suicide Prevention: Bringing Narrative Ideas into Dialogue with Critical Suicide Studies

The purpose of this paper is to explore the conviviality between practices of narrative therapy and the emerging field of critical suicide studies. Bringing together ideas from narrative therapy and critical suicide studies allows us to analyze current suicide prevention practices from a new vantage point and offers us the chance to consider how narrative therapy might be applied in new and different contexts, thus extending narrative therapy’s potential and possibilities. We expose some of the thin, singular, biomedical descriptions of the problem of suicide that are currently in circulation and attend to the potential effects on distressed persons, communities, and therapists/practitioners who are all operating under the influence of these dominant understandings. We identify some cracks in the dominant storyline to enable alternative descriptions and subjugated knowledges to emerge in order to bring our suicide prevention practices more into alignment with a de-colonizing, social justice orientation.