The Role of Stigma and Denormalization in Suicide-Prevention Laws in East Asia: A Sociocultural, Historical, and Ethical Perspective

Associations of Suicide Referents With Different Moral Connotation With Actual Suicides

Background: Different words used for suicide (so-called suicide referents) have different moral connotations, and neutral referents are recommended in media reporting guidelines. Aims: To assess how different referents in media reports are related to actual suicides. Method: Austrian news articles for each month between 2000 and 2021 (n = 276 months) were obtained from the Austrian Press Agency. Time series were modeled for media items referring to suicide as a crime [Selbstmord], an act of freedom [Freitod], or neutral connotation [Suizid]. Temporal associations with suicides in the month before, during, and after the reporting were examined. Results: Terminology referring to suicide as an act of free will [Freitod] was weakly associated with increases in total, male, and female suicides and with suicides in up to 64-year-olds in the same month. No other statistically significant associations were found. Limitations: No detailed content analysis of media reports was done. Conclusion: During times of prevalent use of referents suggesting suicide to be an act of freedom, there are small-sized increases in suicides. The simultaneous occurrence of this referent and suicides might reflect effects of a societal framing present in both the media and the community rather than a sheer media effect.

Interpersonal trauma, shame, and substance use: A systematic review

BACKGROUND

Interpersonal trauma is a risk factor for a wide array of adverse mental health outcomes, including substance use. Research has begun investigating the role of shame in the intersection between substance use and interpersonal trauma. The current systematic review summarizes the existing literature documenting the relation among shame, substance use, and interpersonal trauma.

METHOD

Articles were collected using a Boolean search strategy of terms related to interpersonal trauma, substance use, and shame across six databases. Independent search and screening by three researchers led to a final review of 27 articles, 15 of which were qualitative studies.

RESULTS

Findings highlight robust associations among shame, interpersonal violence, and substance use across varied samples. Findings emphasize that increased shame is associated with greater substance use among survivors of interpersonal violence and elevated shame and greater interpersonal violence are present among individuals who use substances given the high prevalence rates. Burgeoning research suggests that shame mediates the relationship between interpersonal violence and substance use.

CONCLUSION

Results from our review suggest that shame may be an important treatment target for individuals presenting with substance use and a history of interpersonal violence. Future studies, with longitudinal designs, are needed to parse out the temporal relation among shame, substance use, and interpersonal violence.

"Anxiety is not cute" analysis of twitter users' discourses on romanticizing mental illness

BACKGROUND

The proliferation of social media platforms has provided a unique space for discourse on mental health, originally intended to destigmatize mental illness. However, recent discourses on these platforms have shown a concerning shift towards the romanticization of mental health issues. This research focuses on Twitter (now called X) users' authentic discussions on the phenomenon of romanticizing mental health, aiming to uncover unique perspectives, themes, and language used by users when engaging with this complex topic.

METHODS

A comprehensive content analysis was conducted on 600 relevant tweets, with the application of topic modeling techniques. This methodology allowed for the identification and exploration of six primary themes that emerged from Twitter users' discussions. Statistical tests were not applied in this qualitative analysis.

RESULTS

The study identified six primary themes resulting from Twitter users' discussions on the romanticization of mental health. These themes include rejecting/critiquing the glamorization of mental health, monetization of mental health by corporate organizations, societal misconceptions of mental health, the role of traditional media and social media, unfiltered realities of depression, and the emphasis on not romanticizing mental health.

CONCLUSIONS

This study provides valuable insights into the multifaceted discourses surrounding the romanticization of mental health on Twitter. It highlights users' critiques, concerns, and calls for change, emphasizing the potential harm caused by romanticizing mental illness. The findings underscore the importance of fostering responsible and empathetic discussions about mental health on social media platforms. By examining how Twitter users interact with and respond to the romanticization of mental health, this research advances our understanding of emerging perspectives on mental health issues among social media users, particularly young adolescents. The study also underscores the effects of this phenomenon on individuals, society, and the mental health community. Overall, this research emphasizes the need for more responsible and knowledgeable discussions around mental health in the digital age.

Suicide Misconceptions and Attitudes Toward Suicide Prevention Measures in Taiwan

Background: Debunking suicide misconceptions is an important suicide prevention measure. Few studies on suicide misconceptions and their correlates have been conducted in East Asia, where suicide is known to be more permissible. Aims: We investigated the prevalence and associated characteristics of suicide misconceptions in Taiwan. Whether holding suicide misconceptions was associated with reduced support for governmental suicide prevention measures was also assessed. Method: A dual-frame nationally representative telephone survey combining landlines and mobiles was conducted with 1,087 respondents. Logistic regression analyses were used to examine factors associated with suicide misconceptions. Results: Nearly 82% of the respondents held at least one type of suicide misconceptions. The most commonly held misconception was "Talking about suicide would encourage suicide" (49.5%), followed by "People who talk about suicide do not mean to do it" (47.3%) and "Most suicides happen suddenly without any warning" (46.5%). Suicide misconceptions were more common in younger people, divorced/widowed individuals, and those with lower educational attainment. Individuals with suicide misconceptions were less likely to support governmental investments in suicide prevention. Limitations: Causality could not be inferred from the cross-sectional study. Conclusions: Suicide misconceptions are prevalent in Taiwan. Debunking suicide misconceptions should be an integral part of national suicide prevention strategies.

Evaluation of an online suicide prevention program to improve suicide literacy and to reduce suicide stigma: A mixed methods study

Low-threshold e-health approaches in prevention to reduce suicide stigma are scarce. We developed an online program containing video reports on lived experience of suicide and evidence-based information on suicidality. We evaluated the program by a mixed methods design. We examined pre-post-changes of program completers (n = 268) in suicide literacy, suicide stigma (self and perceived), and self-efficacy expectation of being able to seek support in psychologically difficult situations using linear mixed models. To examine reported changes and helpful program elements 12-26 weeks after program completion, we content analyzed transcripts of telephone interviews (n = 16). Program completers showed more suicide literacy (Cohen's d = .74; p < .001), higher self-efficacy expectations to seek support (d = .09; p < .01), lower self-stigma (subscales glorification/normalization: d = -.13, p = .04; isolation/depression: d = -.14; p = .04; stigma: d = -.10; p = .07; n = 168) compared to baseline. We found no significant differences in perceived suicide stigma. We identified lived experience reports, the possibility of sharing own narrative on stigma and suicidality, and information on support as helpful elements. The current online program can increase suicide literacy and self-efficacy expectations to seek support and reduce self-stigma. We recommend a larger randomized controlled trial with longer follow-up to confirm these findings.

The impact of the minimum wage on suicide rates in Hong Kong

Increases in minimum wages have been associated with reductions in suicide rates in the United States, but little evidence is available for Asia where social and contextual factors, as well as drivers of suicide, may be different. We investigated the impact of the introduction of the minimum wage in Hong Kong in May 2011 on suicide rates using an interrupted time series design for the period January 2006 to December 2016. We investigated both immediate and gradual changes in monthly suicide rates after the introduction of the minimum wage taking into account secular trends. We conducted stratified analyses by age and gender. In total 9396 suicides were recorded in Hong Kong during the 11-year study period. Introduction of the minimum wage was associated with an immediate decrease of 13.0% in the monthly suicide rate (95% confidence interval (CI) 5.4%-19.9%, P = 0.001). There was an immediate decrease of 15.8% in older working aged (25-64 years) men (95% CI: 4.2%-25.9%, P = 0.009). Point estimates of immediate effect for other subgroups were also in a negative direction, but were not statistically significant. There was no evidence of a gradual effect on suicide rates at the population level or by subgroup other than a small increase in younger working aged men. We estimate that 633 suicides were prevented by the minimum wage legislation for the period from May 2011 to December 2016, the majority in older working aged men. Our results provide new evidence that, similar to findings in Western settings, minimum wages may help to reduce suicide in Asia, particularly for working age men. Our study highlights the importance of examining the health impacts of government economic policy and suggests minimum wages may provide policy makers with an upstream population-based strategy to reduce suicide rates.

Psychiatric and Psychosocial Factors of Suicide Decedents and Survivor of Suicide Loss: Psychological Autopsy Study of Incheon City in South Korea

In South Korea, the suicide rate is more than double the OECD average, and precise identification of the cause is required for suicide prevention. Psychological autopsy is used to reveal factors related to suicidal behavior; however, such studies are lacking in Korea. This study investigated the factors related to suicide using psychological autopsies in Incheon, a major city in Korea. In total, 46 cases were investigated using the Korea-Psychological Autopsy Checklist (K-PAC), and data on mental health conditions and psychosocial factors of suicide decedents and their families were analyzed. It was estimated that 87% of individuals of suicides had a mental health condition before death, but only 15.2% continued treatment or counseling. Most individuals who died of suicide showed warning signs before death, but only 19.6% of survivors of suicide loss noticed them. Mental health concerns before and after the death of the individual were also identified in more than half of their families. To prevent suicide, intensive and continuous treatment for psychiatric conditions and prompt recognition of active response to suicide warning signs are required. Care for the mental health of family members is also important.

Social Support Reduces the Risk of Unfavorable Parenting Styles for Suicidal Behaviors in Early Adolescents

OBJECTIVE

Depression and perceived stress are important risk factors for suicidal behaviors among adolescents. The current study examined the joint effects of parenting styles on suicidal ideation (SI) and attempt (SA) in early adolescents while considering relevant individual factors, and evaluated whether social support can offset the risk.

METHODS

The present study was part of a large cohort study aiming at tracing the mental health and risk behaviors in adolescents, and we utilized baseline data collected from 645 4th grade students with complete assessment of suicidal behaviors, social support, parental bonding, depression, and perceived stress. Participants' mean age was 9.97 years (SD = 0.38) with 53.02% boys. Logistic regression was performed to analyze the associations between independent variables and youth suicidal behaviors.

RESULTS

16.28% students reported to have SI and 4.96% had SA. Depression (SI: OR = 3.66-3.89; SA: OR = 3.98-4.50), father's low care and high authoritarian (LCHA) (SI: OR = 3.04; SA: OR = 2.43), and low acceptance and high authoritarian (LAHA) (SI: OR = 3.58; SA: OR = 4.77) parenting styles were strong risk factors, while overall social support (SI: OR = 0.98; SA: OR = 0.97) was a protective factor of SI and SA for early adolescents. Perceived stress (OR = 1.07-1.08) and mother's LCHA parenting style (OR = 2.03) were risk factors of SI. Overall, a family with LCHA parenting (OR = 2.82) or LAHA parenting (OR = 3.35-3.72) regardless parental gender had increased risk for SI and SA.

CONCLUSION

Family and social factors are important to consider in suicidal prevention and interventions among early adolescents, in addition to assessing individual risk factors. HighlightsSuicidal ideations (16.28%) and attempts (4.96%) were prevalent in early adolescents at elementary schools. Depression status remains a significant risk factor for both SI and SA in early adolescents.Unfavorable parenting styles (LCHA or LAHA) increased the risk of SI and SA, especially received from father.Overall social support had independent protective effect on suicidal behaviors, when taking aforementioned individual and family risk factors into account.

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

OBJECTIVE

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

DESIGN

A cross-sectional ecological study.

SETTING

171 countries in the world.

PARTICIPANTS

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

MAIN OUTCOME MEASURE

Sex-specific age standardised suicide mortality rates.

RESULTS

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

CONCLUSIONS

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

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

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

Differences in Reactions to Media Reporting of a Celebrity Suicide Between Emotionally Distressed and Nondistressed Individuals in Taiwan

Background: The differences in emotional reactions toward media reports of celebrity suicides between distressed and non-distressed individuals have rarely been explored. Aim: We aimed to explore differences in reaction patterns to the news coverage of a celebrity's suicide between distressed and nondistressed individuals in Taiwan. Method: We conducted an Internet survey to assess the impact of the news coverage of a celebrity's suicide. A series of χ² tests, Spearman's rank correlations, and logistic regression analyses were performed to compare the differences in emotional involvement and psychological impact after exposure to suicide news between distressed and nondistressed individuals. Results: A total of 1,258 Internet users responded to the survey (236 men and 1,020 women). Compared with nondistressed individuals, distressed individuals (n = 537) were more likely to feel suicidal (11% vs. 2%, p < .001) after reading the news. They were less willing to seek help when in need (62% vs. 77%, p < .001). All the variables remained significant after adjustment for sociodemographic variables in regression analyses. Limitations: The Internet-based survey may suffer from selection bias. Conclusion: Extensive media reporting of suicide stories has a profound impact on readers, particularly on vulnerable groups. Responsible reporting of suicide incidents is crucial for suicide prevention.

Does self-esteem inflation mitigate mortality salience effects on suicide attitudes?

INTRODUCTION

Suicide stigma is a major barrier to prevention and intervention efforts. Using terror management theory as the guiding framework, the present study examined whether enhancing self-esteem would buffer against suicide stigma and lead to prosocial attitudes and behavior.

METHODS

Experimental methods were utilized in the present study. After being primed with death-related thoughts, participants were randomly assigned to one of two conditions: (1) positive feedback (experimental group) and (2) no feedback (control group). The dependent variables included (1) evaluations of a suicide decedent, (2) intentions to intervene against suicide, and (3) charitable donation behavior toward a suicide prevention organization.

RESULTS

The most consistent findings for the self-esteem boost hypothesis were for the interaction effects of death anxiety and self-esteem boost for the donation allocation task and intentions to intervene against suicide. For participants who were reminded of death, the self-esteem boost intervention mitigated the negative impact of death anxiety on donation behavior (i.e., an average difference of $16.37). Positive feedback for participants with reported low self-esteem also led to increased willingness to intervene against suicide.

CONCLUSION

These findings provide some promising potential for the self-esteem enhancement intervention to attenuate defensive reactions to suicide.

Posttraumatic stress symptoms, shame, and substance use among Asian Americans

BACKGROUND

To examine the association between posttraumatic stress symptoms (PTSS) and substance use among Asian Americans and the influence of a culturally-relevant moderator, shame.

METHODS

From 2016 to 2017, 199 participants from Amazon Mechanical Turk and a university subject pool completed an online survey. Chi-square and Kruskal-Wallis tests explored demographic and clinical differences among three Asian American ethnic subgroups (East Asians, South Asians, and Southeast Asians). Generalized linear models assessed the association between PTSS and substance use (alcohol, tobacco, and other drugs) and the moderation of this relationship by shame.

RESULTS

Ethnic subgroups significantly differed on all three substance use variables. The severity in PTSS was significantly associated with hazardous drug use (IRR = 1.03, (1.01, 1.05), p = .003). The association between PTSS and days of tobacco use and binge drinking was significantly moderated by shame. Low levels of shame increased the effect of PTSS on binge drinking (IRR = 1.05, (1.00, 1.10), p = .035) and tobacco use (IRR = 1.15, (1.11, 1.19), p < .001). High levels of shame had no effect of PTSS on binge drinking (IRR = 1.01, (0.99, 1.03), p = .54) and a reduced effect on tobacco use (IRR = 1.07, (1.05, 1.09), p < .001).

CONCLUSIONS

Among Asian Americans, the association of PTSS and substance use depends on shame. Lower levels of shame are a risk factor, increasing the effect of PTSS on substance use. Culturally-modified addiction treatments should assess for shame among Asian Americans and attend to ethnic sub-group diversity in substance use.

Suicidal drug overdose following stroke in elderly patients: a retrospective population-based cohort study

PURPOSE

The purpose of this study was to investigate the incidence and risk of suicidal drug overdose (SDO) after stroke in older patients.

METHODS

We enrolled patients aged 60-99 years who were diagnosed with new-onset stroke between 2002 and 2013 and age-, sex-, and index-year-matched controls who did not have stroke. Patients with a history of SDO before enrollment were excluded. Both groups were observed until December 31, 2013. The primary end point was the occurrence of newly diagnosed SDO. The cumulative incidence rates of the study and control groups were estimated using the Kaplan-Meier method. Furthermore, we used the Cox proportional hazards model to identify risk factors for SDO.

RESULTS

We selected 22,770 individuals. Among them, 11,385 were older patients (aged 60-99 years) who had newly diagnosed stroke and 11,385 were controls. Of the 22,770 individuals, 275 (1.21%) had SDO during a mean follow-up period of 5.33±3.30 years, comprising 191 (1.68%) from the stroke group and 84 (0.74%) from the control group. Older patients with stroke had a significantly higher risk of SDO than the controls (adjusted hazard ratio: 2.288, 95% confidence interval [CI]: 1.746-2.999, p<0.001). Moreover, in older patients with stroke, the risk significantly increased with the number of stroke events. Patients with depressive disorder or coronary disease had an increased risk of SDO. Additionally, benzodiazepines and anticoagulants were the two most commonly prescribed medications for SDO.

CONCLUSION

Clinicians should be aware of the risk of SDO and risk factors in older patients with stroke. Psychological assessment and medication monitoring should be incorporated into current clinical diagnoses in neurology and treatments following stroke.